Medical Record Audit

1
Medical Record Audit

• ?.? ????? ???????????
• ????????????????? ????????????????
• ?.?. ??????? ???????????
• ????????????????

2
?????????????????? (Medical Record Audit)

• ??????????
• ????????????????????????????????????
• ??????????????(hospital accreditation )
• ????????????????????????????????????

3
?????????????????? (Medical Record Audit)

• ?????????????????????????????????????
  ?????????????????????????????????
• Resource in hospital
• Diagnosis and treatment
• Outcome of treatment

4
?????????????????? (Medical Record Audit)

• The systematic,critical analysis of the quality
  of medical care for the patient
• The procedures for diagnosis and treatment
• The use of resources
• The resulting outcome
• Quality of life

5
??????????????????????????

• Self-education
• Planning, information on how resources are use
• Evaluate medical care
• Add medical knowledge
• ??????????????????????????

6
Medical record audit

• ???????????? medical audit
• INTERNAL AUDIT
• EXTERNAL AUDIT

7
Medical Audit
1)
Clinical Audit
2)
Financial Audit
3)
Coding Audit
8
Clinical Audit
??????? ??????????? Investigate Dx ???????? ??????
?? ???????
??????? ?????????? ???????
9
Financial Audit
-
Cost ??????
-
Charge ?????????
-
Revenue ??????
-
?????
10
CODING AUDIT

• OBJECTIVE
• CODING STANDARD
• REFERENCE
• AUDITOR

11
THE PROCESS

• ORGANIZATION AUDIT COMMITTEE
• AUDITING TEAM AUDITOR
• AUDIT WORKSHEET
• POST AUDIT SHEET ERROR RATE
• CRITERIA AND ERROR SIGNAL
• POPULATION SAMPLE SIZE TIME FRAME
• TYPE OF AUDIT TO PERFORM

12
?????????????????? (Medical Record Audit)

• ?????????
• ????????????????? ???????????????????????
• Code ICD10 ??? ICD-9-CM ?????????????
• ?????????????????????????
• ????????????????????????? ???????? ???????????
• Check list ???????????

13
???????????????????

• 1. ??????????????????????
• - ???????? ?.?.?./?.?.?. ??? ?.?.?.
• - ??????
• - ?????????????????????
• 2. ????????????????????????????????????????
• 3. ?????????

14
?????????????????? (Medical Record Audit)

• ????????????
• ??????????????
• ?????????? ICD10 / ICD-9-CM
• ???????????????????? (?????)
• ??????????? ??????????????????????????????????????
  ????????????????????

15
?????????????????? (Medical Record Audit)

• ?????????????????????????? Audit
• ( audit team )
• ?????
• ??????
• ???????????????????
• ???????????????????????????????? (option)

16
???????????????????? ???????????????
?????? ????????????????
??????? ???????????????? ???????????
???? ???????????????? ??????????????????????? ????
??????????????
????????? ???????? ???.????????
?.?.????
17
????????????????????
Non OR Procedure ?????????? ?????????? ??????????
?????
OR Procedure ????????? ???????????? ????????????
??? ?????????? ??????????????? ???????????????? ??
??????????? ???????????
18
???????????????

• 1. ??????????, ?????????????? ?????????
• 2. ?????????????????????????????
• 3. ???????????????????????????????
• 3.1 Random sampling
• 3..2 focused sampling
• High and/or low RW
• Problem case
• 4. ????????????????????????

19
?????????????????????????????
1 (HCFA,U.S.A.) 5 (Australian coding
benchmark audit) 40 charts per month for smaller
hospital
20
???????????????????????
?????? ??????? ??? Dx , Investigate , Rx
?????? ?????????
?????? ?????????????
?????? ?????? ????????????
21
???????????????????????
?????? ????????????????
??????????????????????????????
DRG 468 , 469 , 470 , 476 , 477
22
???????????????

• 5. ???????????????????????? audit
• 6. ??????????? ??/????? RW ???? audit
• ???????
• ??????????????????? audit ?????????

23
??????????????? AUDIT

• How and by whom data will be collected
• How often to meet and how long
• What to do with the results
• The educational aspects
• What resources will be needed
• How to preserve confidentiality

24
?????????????????? (Medical Record Audit)

• ????????????????Audit
• ?????????????????????????????
• ???????????????????????
• ???????
• ????????????????
• ?????????????????????
• Admit / Discharge

25
?????????????????? (Medical Record Audit)

• ??????????????
• ??????????????????
• ????????? (60 - 90 ???? ????????)
• ?????????????????????
• ??????????????????????

26
?????????????????? (Medical Record Audit)

• ????????????????
• ??????? ICD 10 vol.1 ??? vol.3
• ??????? ICD-9-CM ?? 2000 (procedure part)
• ?????? DRG version 2.0

27
????????? Chart
??????????????
??????????
??????????(ICD10) ???????????????? (ICD 9 CM)
??????? Discharge Summary
???????

??????? ???????????
???????????????? ???????????????
??????????
28
Medical Record Audit
29
???????????? AUDIT

• HN AN
• Admission date Discharge date
• Length of stay Age
• Correct (Y/N) Payer type
• ????/???????? Discharge status/type
• In MR In Com
• Correct (Y/N)
• Doctor Authentication

30
(No Transcript)
31
Summary and Coding Audit

• ???????? ????????? ?????????????? ????????????
  ??????????????????? Discharge Summary
  ???????????????????? Computer

PDx ????????????????????????????????????????
????? Other Dx ???????? Op ????????????
??????????? ???????????????????? PDx
32
???????????? AUDIT

• ???????
• Diagnosis in computer (List ?????????????????????)
  ???????? ICD in computer
• Diagnosis from summary sheet
• Diagnosis from review of medical record

33
???????????? AUDIT

• ??????? ICD10 ??? ICD-9-Cm
• ?????? S ICD
• ???????????? summary sheet
• ?????? R ICD
• ????????????????????????????????

34
???????????? AUDIT

• ?????????????????????
• In COM ??? R ICD
• S ICD ??? R ICD
• ?????? R ICD ????????

35
???????????? AUDIT

• ???????????????????????????????????????????
• ??? R ICD ??????? S ICD ????????????? summary
  assessment ???? ?????? SA
• ??? 8 ??? In com R ICD ???????????? S ICD
  ?????? CA (code assessment ??? 8)
• ??? 7 ??? In com S ICD ???????????? R ICD
  ?????? CA (code assessment ??? 7)

36
???????????? AUDIT

• ??? ICD ??? In COM ??????????? R ICD ??? S ICD
  ????????????? Code Assessment ???????? CA
• ????????????
• Summary Assess
• Code Assess
• ???????????? ?????? 0

37
Medical Record Audit
HNAN..DrDepartment.. Admit date
Discharge date LOS. ??????? 1 Summary and
Coding Audit In Summary Sheet S
Audit ICD ICD in C audit
Remarks
Computer
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
38
Medical Record Audit
In Summary Sheet ??????? ???????? (??????????????)
HNAN..DrDepartment.. Admit date
Discharge date LOS. ??????? 1 Summary
and Coding Audit In Summary Sheet
S Audit ICD ICD in C audit
Remarks
Computer
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
39
Medical Record Audit
HNAN..DrDepartment.. Admit
date Discharge date LOS. ??????? 1
Summary and Coding Audit In Summary
Sheet S Audit ICD ICD in C
audit Remarks

Computer
S Audit ????????????????? 4??????? 8??? ?
???????????
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
40
Medical Record Audit
HNAN..DrDepartment.. Admit
date Discharge date LOS. ??????? 1
Summary and Coding Audit In
Summary Sheet S Audit ICD ICD in
C audit Remarks

Computer
ICD ??????????????? ???Auditor
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
41
Medical Record Audit
HNAN..DrDepartment.. Admit
date Discharge date LOS. ??????? 1
Summary and Coding Audit In
Summary Sheet S Audit ICD ICD in
C audit Remarks

Computer
ICD in Computer ????????????????????? ????????????
?
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
42
Medical Record Audit
HNAN..DrDepartment.. Admit
date Discharge date LOS. ??????? 1
Summary and Coding Audit In
Summary Sheet S Audit ICD ICD in
C audit Remarks

Computer
C Audit ?????????????? Code ??? Auditor ???
????????????????? 4??????? 8???
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
43
Medical Record Audit
HNAN..DrDepartment.. Admit
date Discharge date LOS. ??????? 1
Summary and Coding Audit In
Summary Sheet S Audit ICD ICD in
C audit Remarks

Computer
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
????
????? ??????????
???? ??????????
44
Medical Record Audit
DRG ??????? ICD ?????????????
HNAN..DrDepartment.. Admit
date Discharge date LOS. ??????? 1
Summary and Coding Audit In Summary
Sheet S Audit ICD ICD in C
audit Remarks

Computer
DRG ??????????? ??? Auditor
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
-
4
8

4
45
Medical Record Audit
HNAN..DrDepartment.. Admit date
Discharge date LOS. ??????? 1 Summary and
Coding Audit In Summary Sheet S
Audit ICD ICD in C audit
Remarks
Computer
Acute Appendicitis
K350
K359
8
Rupture
8
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
4
Appendectomy
470
470
4
45
45
4
4
2
2
4
4
1
1
4
4
165
167
8
-
1.29
0.77
1
46
????????? Summary and Coding Audit

• ICD in com ???? ICD ?????????? Computer
• Dx/Op in Summary Sheet Dx/Op ??? Discharge
  Summary
• S ICD ?????????? ICD ??? Auditor ??? Dx/Op ??
  Discharge Summary
• Dx/Op From Review Dx/Op ????????????????????????
  ? Auditor
• R ICD ?????????? ICD ??? Dx/Op From Review
• SA ?????????? Dx/Op ?? Discharge Summary
  ?????????????????
• CA ???????????????????? Dx/Op ??? Coder
  ?????????????????
• Remark ???????????????????? Auditor

47
????????? Summary and Coding Audit

• ??????????? ICD in Com , S ICD, R ICD ?????? R
  ICD ????????
• ??? S ICD ?????? R ICD ?????? ??????????????????
  0 ?????? SA
• ??? S ICD ??????? R ICD ???????????????? Summary
  Assessment ?????? SA
• ??? ICD in Com ?????? R ICD ??? S ICD ??????
  ?????????????????? 0 ?????? CA
• ??? ICD in Com ?????? R ICD ?????????? S ICD ???
  8 ?? ???? CA
• ??? ICD in Com ??????? R ICD ???????????? S ICD
  ??? 7 ?? ???? CA
• ??? ICD in Com ??????? R ICD ??? S ICD
  ???????????????? Code Assessment ?????? CA

48
????????? Summary and Coding Audit

• Summary Assess ???????????????????????? Dx/Op
  ?? Discharge Summary
• Code Assess ???????????????????????? ??? Coder
• DRG in Computer DRG ????????? ICD in Computor
• Auditor ,s DRG From R ICD DRG ????????? R ICD
• RW in Computor ??? RW ????????? DRG in Computer
  
• Auditor ,s RW From R ICD ??? RW ????????? DRG
  From R ICD

49
Scoring tool form

• Summary assessment
• Coding assessment

50
??????????? Summary Assessment

• 0 No disagreement
• ???????????????????????????????? Dx ??? Op ??
  Discharge Summary
• 1 Ambiguous principal diagnosis
• ????????????????????? ???????? principal
  diagnosis ???????????????? Auditor

51
??????????? Summary Assessment

• 2 Incorrect Principal Diagnosis
• ???????????????????????????? ?????????
  ??????????????????
• ???????? principal diagnosis ??? specific

52
??????????? Summary Assessment

• 3 Incorrect sequencing
• Principle diagnosis and / or operative code
  ??????????? sequence ??????????

53
??????????? Summary Assessment

• 4 Incorrect other diagnosis
• ????????????????????? 2,3 ???????

54
??????????? Summary Assessment

• 5 Incorrect operation
• ????????????????????
• ?????????????????????????????

55
??????????? Summary Assessment

• 6 Terminology not the same as in ICD10 / ICD9CM
• ??????????????????????????? ICD
  ?????????????????????????????????????????? ICD

56
??????????? Summary Assessment

• 7 Unclear terminology / document
• ??????????
• ??????????? ?????
• ??????????????????????

57
??????????? Summary Assessment

• 8 Inconsistent documentation
• ??????????????????????????????? ???? ??????????
  ????? Dx ???? Op ??? discharge summary ?????????
  Auditor

58
??????????? Summary Assessment

• 9 Other problem
• ????????? ?

59
??????????? Code Assessment

• 0 No disagreement
• ????????????????????
• 1 Inappropriate use of .8 .9
• ??????????????????? ??????????????????????????????
  ????

60
??????????? Code Assessment

• 2 Coding rules not followed
• ????????????????????? ??????????????? ICD

61
??????????? Code Assessment

• 3 Unjustified additional code
• ??? code ??????????? medical record

62
??????????? Code Assessment

• 4 Missing code
• ???. ??? / ?? ?????????? (??????????? Discharge
  summary ??? )

63
??????????? Code Assessment

• 5 Other error in coding
• ??????????????? ? ????
• urinary bladder VS gall bladder
• 0233 (ventriculopleural anastomosis) VS 0234
  (ventriculoperineostomy)

64
??????????? Code Assessment

• 6 Clerical error
• ????????????
• Operation code 530 - Unilateral repair of
  inguinal hernia
• ????????????? 503 - Lobectomy of liver

65
??????????? Code Assessment

• 7 Code disagreement due to summary disagreement
• ??????? auditor ??? coder ??????? ????????? Dx /
  Op ??? auditor ?????????? doctor

66
??????????? Code Assessment

• 8 Justified modifying of code or sequence, or
  additional code
• ?????? Discharge summary ??????????????? ???.
  ??????????????????????????? ??????????????????????
  ??????

67
??????????? Code Assessment

• 9 Other problem
• ????????? ?

68
????????????????? score ??????????????????
??????????????????????????
69
Summary Error
Incorrect principal Dx
1)
???? ??????????????????????????????????
Terminology not the same as in ICD
2)
???? ???/????????? ????????? ICD
Incorrect sequencing
3)
?????????? ??? / ????????? ????????????????? ICD
4)
Incorrect additional Dx
???? ?????? 2 ,3 ??????? ??????????????
70
Summary Error
Incorrect Operation
5)
???? ???????????????? ??????????
6)
Principal operation not related to principal Dx
???? ????????? ??? Dx ?????????
Incorrect Age
7)
?????????????
Incorrect discharge status
8)
???? ????? ?????????? ???????
71
Coding Error
Ambiguous principal Dx
1)
??????????? ????????????????
Terminology not the same as in ICD
2)
???? ????????? ????????????????????????????????
Use of unfound code
3)
???? ??? / ??????????????????????? ??????? ICD
4)
Clerical error
????? ??????????? ????????? ?????? ???????
??????????????
72
Coding Error
Coding rules not followed
5)
???????????????? ?????????? ICD
Missing Code
6)
????????? ?????? ??????????????????????
Justified additional code
7)
???????????????? ??????????????????????
Unjustified additional code
8)
????????? ????????? ?????????? ???????????????
73
????????? AUDIT ??????

• ???????????
• Lead to DRG change ??????? (????????)
• ??????????????????????????????????
• Staff
• ???????
• ?????

74
Medical record

• Document
• Documentation standard

75
Medical record ( ?????????? )

• ???????
• ?????????????????????

76
??????????????????????????????????

• ?????????????????????????????????????????
• ???????????????????????????????????????????
• ???????????????????????????????

77
(No Transcript)
78
????? Medical Record Audit ?????? 2

• ??????? Content ?????????????
• Check list ??? ?????????????????????? 11 ????
• ??????????? ?????????? ??????????????????

79
????????????????????????????????????

• NA (8) ??????????????? (Not Applicable)
• Miss (9) ?????????????????? ??????????????????
• No (0) ???????? ?????????????????
• Poor (1) ??? ???????????????
• Fair (2) ????? ???????????????????
• Good (3) ??????????????????
• Excellent (4) ???????? ?????????????

80
?????????????????????? 11 ????

• Physician discharge summary
• Informed consent
• History
• Physical examination
• Progress note

81
?????????????????????? 11 ????

• Operative note
• Anesthetic record
• Labour record
• Consultation record
• Rehabilitation record
• Nurses note

82
Physician discharge summary ?????

• ???????????????????????
• ????????? Ruled of ICD (??????? ??????? ???????)
• ?????????????????????????????????
• ????????? Ruled of ICD
• ??????????????????
• ???????????????????????

83
?????????? physician discharge summary

• ???????????
• ???????????
• Sequence
• ????????????
• ????????

84
??????????? Physician discharge summary

• Poor ????????????????, ?????????????????,
  ???????????? Ruled
• Fair ????????? ?? Principle diagnosis w / wo
  Operative code
• Good ???????? ??????????
• Excellent ?????? Ruled ??? ICD
  (???????????????????????????)

85
Informed Consent ?????

• ??? ????? ?? (???????) ???????????????????????????
  
• ????????????????????
• ????????????????????
• ????????????
• ????
• (Option)
  
  

86
???????????????????? ??????????????? ???????????
??? ????????????????????? ?????????????????????
???????????????????????????????? ???????????????
???????????????? ?????????????????????????????
87

• ????????????????????
• ????????????
• ??????????????????????????????????
• ???????????????????????????????????
• ????????????????????????????
• ????????????????

healthlink.mcw.edu/content/article/28853/972937152
.html
88
Informed consent

• Poor ?????????? ???????????? Identify
  ??????????
• Fair ??????????, Identify ??? ???????????????
  
• Good ???????? ?????????????????????
• Excellent ?????????????????????????

89
?????????????????????

• Chief complaint
• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associate signs and symptoms

90
?????????????????????

• Present illness
• Chronological description of development of
  patients present illness from the first sign
  symptom to the present
• Details of present illness
• What
• Where
• When
• Why
• Who
• How
• How many

91
?????????????????????

• ???????????????????
• Prior surgery,illness,hospitalization
• Allergies,current medication
• Immunological status
• ??????????????????????????
• occupational
• Use of drug,alcoholic intake
• Sexual history

92
?????????????????????

• Family history
• Diseases of family members
• Health status or cause of death of
  parents,children,siblings
• ????????????????????????
• Vaccine, growth development ??????
• ????????????????

93
History

• Poor ????? Chief complaint
• Fair ??? What Where When Why Who How
• How many ?????????????
• Good ???????? ???????????????????????
• ?????????????
• Excellent ????????????????

94
Documentation standard

• History
• Problem focused
• Expanded problem focused
• Detailed
• comprehensive

95
???????????????????

• Vital sign
• ??????????????????
• ?????????????????????????????/????? ??????????
• ??????????????
• ??????????????????????

96
Physical examination

• Poor ?????????????? complain
• Fair ??? ??????????????????? Diagnosis ???
• Good ???????? ???????????????????????????
• ????????
• Excellent ???????????? ???????????

97
Documentation standard

• Physical examination
• Problem focused
• Expanded problem focused
• Detailed examination
• Comprehensive examination

98
Progress notes?????

• ???????????????????????????????????????????????
• ??????????????????????????????????? / ?????
• ?????????????????? Invasive Procedures
• ?????? ?? 3 ??????
• ????????????????????????????
• ???????????????????????????????????????
• S.O.A.P. format

99
Progress note

• Poor ???????? ???????????????
• Fair ???????????
• Good ??????????????????????????????????
• Excellent ?? Subjective, Objective, Assessment
• ??? Plan ??????

100
????????????????????

• Preoperative diagnosis
• Postoperative diagnosis
• ?????????????? ?????????????
• ????????????????????????
• ??????????
• ??????????
• ???????????????? ???/???? ????????????????????

101
Operative note

• Poor ???????? finding, ???? finding ??????,
  ?????? operation ??????
• Fair ????????????????????????????
• Good ?? Operative technique ??? Finding ??????
• Excellent ???????????

102
??????? Content ?????????

• Anesthetic record
• ?????????????????????????
• Techniques ??????????
• Input / output ???????????
• Patient status ??????? 2 ???????? .
• Diagnosis ??????????? Dr.'s diagnosis

103
Anesthetic record

• Poor ?????????? ???????????????????????????????
  ??
• Fair ?????????????????????????? ?????????
• Good ??????????????????????????
  ?????????????????

104
Labour record

• Condition ?????
• Physical status
• Progress of labour
• Condition ???
• Progress of labor

105
Labour record

• Poor ?????????? ????????? ??? ???? finding
  ??????
• Fair ?????????/?????????/???????????????????
• Good ?? Operative technique ??? Finding ??????

106
Consultation record ?????

• ?????????????????????????????
• ????????????????????????????
• ??????????????????????????????
• Adjust ??? case
• ????????????????????

107
Consultation record

• Poor ????????????????? ???? ??? consult ?????
  (Adjust ??? case) ???????????????? ???????????
• Fair ?????????????
• Good ???????????????????????????????????????????
  ????
• Excellent ?????????????????

108
Rehabilitation record ?????

• ???????????????
• ?????? ???? ???????
• ???????????????
• ???????????????
• ????????

109
Rehabilitation record

• Poor ??????????????
• Fair ??????????? Rehabilitation ?????????????
• Good ?? Operative technique ??? Finding ??????
• Excellent ???????????????????

110
Nurse note helpful

• ??????????????????????????
• ????????????????????????
• Vegetative function
• ?????
• ???????
• ??????????

111
Nurse note helpful

• Poor ?????????? ????????? Initial paper
  ????????
• Fair ??????????????????????
• Good ???????????????????????????????
• Excellent ?? Subjective, Objective, Assessment
  ??? Plan ??????

112
Medical Record Audit
??????? 2 Quality of Medical Record Contents
Content of medical record Not applicable
Missing No Poor Fair Good
Note Physician discharge summary
Na m 0
1 2 3
.. Consent
Na m
0 1 2 3
.. History
Na
m 0 1 2
3 .. PhysicalExam
Na
m 0 1 2
3 .. Progress note
Na
m 0 1 2
3 .. Operative note
Na
m 0 1 2
3 .. Anesthetic record
Na
m 0 1 2
3 .. Labour record
Na
m 0 1 2
3 .. Consult record
Na
m 0 1 2
3 .. Rehab record
Na
m 0 1
2 3 .. Nurses note
Na
m 0 1
2 3 ..
Physician discharge summary ?????? ??.501 , 502 ,
503
Consent ????????????? / ??????
113
Medical Record Audit
??????? 2 Quality of Medical Record Contents
Content of medical record Not applicable
Missing No Poor Fair Good
Note Physician discharge summary
Na m 0
1 2 3
.. Consent
Na m
0 1 2 3
.. History
Na
m 0 1 2
3 .. PhysicalExam
Na
m 0 1 2
3 .. Progress note
Na
m 0 1 2
3 .. Operative note
Na
m 0 1 2
3 .. Anesthetic record
Na
m 0 1 2
3 .. Labour record
Na
m 0 1 2
3 .. Consult record
Na
m 0 1 2
3 .. Rehab record
Na
m 0 1
2 3 .. Nurses note
Na
m 0 1
2 3 ..
History ??????????????????
Physical Exam ??????????????
Progress note ?????????????????? ??????????????
114
Medical Record Audit
??????? 2 Quality of Medical Record Contents
Content of medical record Not applicable
Missing No Poor Fair Good
Note Physician discharge summary
Na m 0
1 2 3
.. Consent
Na m
0 1 2 3
.. History
Na
m 0 1 2
3 .. PhysicalExam
Na
m 0 1 2
3 .. Progress note
Na
m 0 1 2
3 .. Operative note
Na
m 0 1 2
3 .. Anesthetic record
Na
m 0 1 2
3 .. Labour record
Na
m 0 1 2
3 .. Consult record
Na
m 0 1 2
3 .. Rehab record
Na
m 0 1
2 3 .. Nurses note
Na
m 0 1
2 3 ..
Operative note ???????????????
Anes record ?????????????
Labour record ?????????????
115
Medical Record Audit
??????? 2 Quality of Medical Record Contents
Content of medical record Not applicable
Missing No Poor Fair Good
Note Physician discharge summary
Na m 0
1 2 3
.. Consent
Na m
0 1 2 3
.. History
Na
m 0 1 2
3 .. PhysicalExam
Na
m 0 1 2
3 .. Progress note
Na
m 0 1 2
3 .. Operative note
Na
m 0 1 2
3 .. Anesthetic record
Na
m 0 1 2
3 .. Labour record
Na
m 0 1 2
3 .. Consult record
Na
m 0 1 2
3 .. Rehab record
Na
m 0 1
2 3 .. Nurses note
Na
m 0 1
2 3 ..
Consult record ????????????????????
Rehab record ?????????????????
Nurses note ???????????????
116
Medical Record Audit
Summary Error ??????????? ?????????? 1 2 3 4
5 6 7 8
HNAN..DrDepartment.. Admit
date Discharge date
LOS. ??????? 1 Summary and Coding Audit
In Summary Sheet S Audit ICD
ICD in C audit Remarks

Computer
Coding Error ??????????? ???????????? 1 2 3 4
5 6 7 8
Type of Error ??????? ???????????
Dx1 Dx2 Dx3 Op1 Op2 Age D/C Status D/C
type DRG DRG Weight Type of Error Summary
Error
Coding Error
117
???????????

• Full score
• ???????????????? content ??????????????????
• Sum score
• ????????????????????????
• ?????? NA Miss

118
Overall findings ( ) 1. Documentation inadequate
for meaningful review (?????????????????????????)
( ) 2. No significant medical record issue
identified (??????????????????????????) ( ) 3.
Certain issues in question, specified
(??????????????????????????????? ????)
Auditor Date .
119
????????? AUDIT ?????????

• ???????????????????????????????? Overall findings
• 1 ?????????????????????????
• 2 ??????????????????????????
• 3 ??????????????????????????????? ???? ..

120
????????? AUDIT ?????????

• ?????? Auditor ???????????????????????????????????
  ?????

?????????????????
121
POST AUDIT

• Error rate too high
• Report
• feedback

122
Error rate too high

• gt 20
• ????????? re-audit ????? 30 ???
• ??????????????????????????????????????????
• ????????????????????
• ???????????????????????????????? ( focused
  sampling) ???????? ???????????????????????? (
  continuous quality improvement )

123
The audit cycle
Plan care Implement change
Agree criteria set target standards
Evaluate information performance versus targets
Observe practice collect data
124
????? AUDIT ???????????? ?????????

• ????????????????? Summary sheet
• ???????????????? Computer ????
• Run Grouper ???
• ????????? DRG ????? 468, 469, 470, 476, 477 ???
  feedback ?????????????????????????????

125
Post audit

• FEEDBACK

126
????? AUDIT ???????????? ?????????

• ?????????????????????????????????????????
• Medical record content
• Summary error
• Coding error
• ??????????????????????????????????????????????????
  ????????????????????????????????????????????

127
????? AUDIT ???????????? ?????????

• ????????????????????????????? ????????????????????
  ??????
• ?????????????????????????????????
• ????????? RW ???????
• ????????? RW ???????
• ??????????????? RW ????????????????????????
• ????????????????????

128
????? AUDIT ???????????? ?????????

• ??????????
• ????????? ----gt ??????????
• ???????????? ----gt ?????????????????
• Auditor ----gt ???????????????????????

129
???????????

• ????????????????????? Correct (Y/N) ????? Item
• ?????????????????????
• Summary assessment
• Code assessment
• ?????????????????????
• ?????????????? Content of Medical Record
• ????? Item ??? Content of Medical Record

130
???????????

• ??????????????? Missing
• ?????????? Overall findings
• ??? 1 ?????????
• ??? 2 ?????????
• ??? 3 ?????????

131
??????????? DRG ??????????

• DRG 468 Extensive OR Procedure Unrelated to
• Principal Diagnosis (RW 3.6202)
• DRG 469 Principal Diagnosis Invalid as
  Discharge
• Diagnosis (RW 0.0000)
• DRG 470 Ungroupable (RW 0.0000)
• DRG 476 Prostatic OR Procedure Unrelated to
• Principal Diagnosis (RW 2.2234) (???)

132
??????????? DRG ??????????

• DRG 477 Nonextensive OR Procedure Unrelated to
  Principal Diagnosis (RW 1.7461)

133
Extensive O.R. Proc. Unrelated to Principal Dx
DRG 468
DRG 469
Principal Dx invalid as Discharge Dx
DRG 470
Ungroupable
Prostatic O.R. Proc. Unrelated to Principal Dx
DRG 476
Non extensive O.R. Proc. Unrelated to Principal
Dx
DRG 477
134
??????????????????? Audit

• ??????????????????????????
• ?????????????????????????
• ????????????????????
• ????????????????????
• pradit_at_health.moph.go.th

135
EXPERIENCE FROM SIP
136
???????????????????? (Medical Record Audit)

• ??????????
• ??????????????????????
• ?????????????? ICD
• ??????????????????????????
• ????????????? ??? ?????????????????????
• ????????????????
• ?????????????????????????

137
???????????????????? (Medical Record Audit)

• ??????????
• ????????????????????
• ??????????
• ???????????????????
• ????????
• ????????????????????????

138
???????????????????? (Medical Record Audit)

• ?????????????????????? (1396 ????)
• ?????????? 77.6
• ??????????????????????????? 15.2
• ????????????????????????? 7.1

139
???????????????????? (Medical Record Audit)

• ????????????????????? 36.5 ???????
• ????????????????????????? 7.5
• ?????????? 5.4
• ???????????????????????? 4.6
• ???????????????? 4.4
• ???????????????????????? 3.8
• 14.9 ????????????????????????? DRG

140
???????????????????????

• Discharge summary ????? 2 ??
• ?????????????????? 77.42 74.19
• ?????????????? 50 51.04
• ???????????? DRGs 60.76 58.49

141
???????????????????????

• ?????? ????? 2 ??
• ???????????????? 26.88 17.89
• ????????????????? 43.16 38.54
• ????????????? 53.89 45.45
• ?????????????? 46.11 39.39
• ?????????????????? 48.96 50.00

142
?????????????????? (Medical Record Audit)

• ???????????????
• ?????????????????????????????
• Program Grouper
• ????????

143
??????????? ??/????? RW ???? audit

• ??????????????????????? RW
• ??????????????????? audit
• Length of stay
• Type of discharge

144
(No Transcript)
145
????????? RW ???? LOSlt 1/3 WTLOS

• Los 0 day AdjRW 0.23 RW
• Los 1 day AdjRW 0.33 RW
• Los 2 days AdjRW 0.67 RW
• Los 3 days AdjRW 0.71 RW
• Los 4 days AdjRW 0.75 RW
• Los 5 days AdjRW 0.79 RW

• Los 6 days AdjRW 0.83 RW
• Los 7 days AdjRW 0.87 RW
• Los 8 days AdjRW 0.91 RW
• Los 9 days AdjRW 0.95 RW
• Los 10 days AdjRW 0.99 RW

146
?????????? ????????? ???????

• ?????? RW ??????????? LOSltWTLOS
• ??????????
• Adj RW RW/WTLOSLOS

147
??????????????????? LOSgtOT (OTgt0)

• ????????? RW ??????????? LOSgtOT (OTgt0)
• ?????????????
• AdjRW RW1(RW/2/WTLOS)(LOS-OT)

148
??????? RW ?????????????

• ??????????????????? ????? LOSlt1/3 WTLOS
• ?????????/????????? ????? dischtgt1 ??? LOSltWTLOS
• ?????????????????? ????? LOSgtOT (OTgt0)

149
????????????
??? LOS gt Wtlos/3
??? RW ????
?????? RW ?????? K (??????) x RW
??? LOS lt Wtlos/3
??????????????
????????????
??? Discht 1
RW
K ?????? x RW
(RW/wtlos)x LOS
Discht ltgt 1
RW
K ?????? x RW
????? adj RW
150
???????????????????????

• Discharge summary ????? 2 ??
• ?????????????????? 77.42 74.19
• ?????????????? 50 51.04
• ???????????? DRGs 60.76 58.49

151
???????????????????????

• ?????? ????? 2 ??
• ???????????????? 26.88 17.89
• ????????????????? 43.16 38.54
• ????????????? 53.89 45.45
• ?????????????? 46.11 39.39
• ?????????????????? 48.96 50.00

152
???????????????

• 5. ??????????? ??/????? RW ???? audit
• 6. ???????????????????????? audit

153
DRG ??????????????? audit ()
154
DRG ??????????????? audit ()
155
???????????????????????? audit
156
???????????????????????? audit
??????? 1 ?????? 100 ???? AUDIT ????????
40,000,000 ??? RW ???
15,014.47 ????? unit???RW ????? 2,664.10
???
??????? 2 ?????? 80 ???? AUDIT 80
??????????? 32,000,000 ??? RW ??? ????
Audit 15,014.47 ?????unit??? RW ???? Audit
????? 2,131.28 ??? RW ???????Audit
10,933.19 ????? unit??? RW ???? Audit ?????
3,658.58 ??? ( 100 ???????????)
157
?????????????????
??????? 1
158
??????? 2
159
??????????? DRG ??????????

• DRG 468 Extensive OR Procedure Unrelated to
  Principal Diagnosis
• (RW 3.6202)
• DRG 469 Principal Diagnosis Invalid as
  Discharge Diagnosis
• (RW 0.0000)
• DRG 470 Ungroupable
• (RW 0.0000)
• DRG 477 Nonextensive OR Procedure Unrelated to
  Principal Diagnosis
• (RW 1.7461)

160
DRG 468,469, 476,477(??????? SIP)
161
DRG 468,469,476,477
162
DRG 470 (??????? SIP)
163
????????????????????????????? ()
???????????????? ????? ????????? SIP 383 29.12
Non-SIP 1251 32.36 ??? 1634 31.60
164
????????????????????????????? ()
165
?????????????? Audit ?????????????????? ???????
SIP
166
?????????????????????????(Overall
Findings)??????????????????
167
??????? AUDIT ??? ????????????????
168
??????? AUDIT ??? ????????????????
169
??????? AUDIT ??? ????????????????
170
???????????????? ??? ?????????????????????????
(???.)
171
?????????????????????????(Overall
Findings)???????????????????
172
???????? ????? Audit ??42 ???????????????????
????? DRG ??????? 22 ??? ??????? 75.86 ????????
RW ??? ????????? ??? 31.32 ???? 47.26
(?????15.94)
173
???????? ?????????????? ????? Audit
Summary Assess
(0) No disagreement 34.48 (1) Ambiguous
Principal Diagnosis 3.45 (2) Incorrect
Principal Diagnosis 17.24 (3) Incorrect
Sequencing 6.90 (4) Incorrect Other
Disgnosis 44.83 (5) Incorrect
Operation 34.48 (6) Terminology not the same
in ICD - (7) Unclear terminology/document
- (8) Inconsistent documentation 10.34 (9)
Other problem 3.45
174
???????? ?????????????? ????? Audit
Code Assess

• (0) No disagreement 37.93
• (1) Inappropriate use of .8 .9 6.90
• (2) Coding rules not followed 20.69
• (3) Unjustified addition code 10.34
• (4) Missing code 65.52
• (5) Other error in coding 68.97
• (6) Clerical error 3.45
• Code disagreement due to summary
  disagreement 55.17
• (8) Justified modifying of code or sequence or
  additional code 17.24
• (9) Other problem 20.69

175
???????? ????????????????????????????????? Audit
(?????????????)
Content of Medical Record NA Miss No Poor
Fair Good Excellent Discharge
summary Dx Op 0 0 0 45
41 7 0 Discharge summary
Others 0 0 0 38 52
3 0 Informed Consent 0
69 0 31 0 0
0 History 0 0 62 24
14 0 0 Physical
examination 0 10 59 17
10 3 0 Progress note
0 86 7 7 0 0
0 Operative note 45 31 14
3 3 3 0
Anaesthetic record 45 21 0 24
10 0 0 Labour record
100 0 0 0
0 0 0 Consultation
record 83 17 0 0 0
0 0 Rehabilitation record
86 14 0 0 0 0
0 Nurses note helpful
3 17 0 79 0 0
0
176
???????? ?????????????????????????????????????
Full score (??? 29 ????) 923 Sum score (???
29 ????) 169 ????????????? 18.31
177
?????????????????????

• ???????????????? audit
• ????????????????????????????? audit
  ????????????????
• ????????????????????????????
• ??? 1 ???? ??? 2 auditor ??????
• ?? care map audit
• ????? care map
• ?????????? care map