The Importance of Clinical Documentation in the MalaysianDRG Casemix System: A Sequential Explanatory Mixed-Method Study of Ministry of Health Hospitals in Malaysia

ABSTRACT

@#Introduction: The Ministry of Health (MOH) implemented the MalaysianDRG casemix system in 2010, and two national target indicators on the accuracy and completeness of clinical documentation were introduced to measure its performance. This study aims to show the trend of casemix performance in MOH hospitals and to explore the challenges in meeting these targets. Methods: The study design was sequential explanatory mixed-method design. First, a cross-sectional study described the trend of casemix performance in five MOH hospitals in Malaysia. Second, a single holistic case study of the hospital with the lowest casemix system performance was conducted to explore the perceptions of clinicians regarding the MalaysianDRG casemix and the challenges pertaining to clinical documentation. Purposive sampling was employed, and the case study data collection was carried out using in-depth-interviews, observation, and document reviews. Results: Two hospitals achieved the target in the accuracy of clinical documentation for the main condition (≥90%). For completeness in clinical documentation, four out of five MOH hospitals performed below the target (≤ 60%). Thematic analysis of the data found poor commitment of clinicians towards casemix and a multitude of obstacles in performing clinical documentations. Conclusion: After a decade of its implementation, the performance of the MalaysianDRG casemix system in MOH hospitals is still moderate due to inaccurate and incomplete clinical documentations. The study findings may be used to spread awareness and devise tailored solutions to assist clinicians in paving the way towards future excellence in MalaysianDRG casemix system.