[Quality of medical records as a basis for DRG classification in the health care system in Bosnia-Herzegovina].

Medical Record contains data about use of health care services of every member of certain population, no matter if they come from preventive or curative health care. Quality of Medical Records is very often in direct as well as indirect connection with health care quality. Better health care systems usually have better Medical Records. These are computer processed and stored on some of contemporary computer media, like: disks, microfilms, magnetic tapes and so-called "smart cards". Good Medical Record should have at least next characteristics: 1. Time dimension, which should contain chronological: past, present and future data, relevant to health care consumers. 2. It should be complete in a sense that every Medical Record must contain adequate medical and other relevant data for health care planning, organization and control. From the aspects of our research described here, it is very important that Medical Records contain all financial data. These usually are consequences of consumption of health care services from various resources of different levels. The results of our research about the application of DRG classification in B&H health system, that have been done in Tuzla University-Clinical Center, show that hospital Medical Records have many inadequacies, both in respect of medical as well as non-medical part. Physicians use very little ICD coding system. There is no uniform anamnesis, no detailed evidences about all hospital services, no adequately defined severity of disease and patient status at discharge. Due to manual based information system, there is no evidence about spending of resources per patient with financial data. The development and application of computer based health information system must go towards direction of solving these problems.