| What is a Documentation Audit - And Does Your Organization Need One? |
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It seems that we are, as an industry, fairly adept at the coding audit process. If the hospital’s case mix decreases, we perform a coding audit. If the OIG begins a new investigation, we perform a coding audit. If we want to make sure our billings are correct, we perform a coding audit. What happens when our coding audit findings are consistently accurate? Does that mean we’ve done all we can do? Better yet, how much thought and attention have we given to the "pre-cursor" to the coding process – the physician’s documentation? Is there some review or some audit process that we can employ to identify the potential that a patient record has been "underdocumented", contains "documentation ambiguities", or some other documentation atrocity? In this article, we explore the concept of a documentation audit and what it might do for your organization. What is a documentation audit? A documentation audit is a review of the physician’s documentation in the patient’s medical record to determine if the documentation is reflective of the care provided to the patient. Documentation should always be driven by care, and not vice versa. But often, the physician leaves in his/her mind, the most important pieces of information – that could have made an impact, if documented. A documentation audit can be performed on patients in every setting – from the physician’s office to the ED to the inpatient setting. The need for high quality documentation is consistent throughout every provider setting. However, because physician’s time is limited, it is also important that they be aware of the types of documentation that can have an impact on reimbursement. Physician care and documentation should not be driven by these criteria – but physicians should be aware of the criteria. Why should you perform a documentation audit?There are multiple reasons why you might want to perform a documentation audit. In summary, a documentation audit can identify documentation omissions that could:
How do you perform one? For the highest degree of effectiveness, a documentation audit should be performed concurrently, while the patient is being treated. In the case of the physician in the ED or the clinic/office setting, this means a "shadowing" of the physician by a clinician/documentation expert. In the case of the inpatient setting, the documentation review needs to take place on the nursing units while the patient is still in-house. The review should involve the objective assessment of whether the documentation in the record is representative of the care provided. During the review, data should be collected that represent when a documentation deficiency was identified and what (if anything) was done by the physician about the documentation deficiency. What do you do with the results? You need to collect the results of each record or documentation episode that you reviewed. In particular, you should identify if there was any action from the physician when the possible documentation deficiency was pointed out to him/her. This way, you can identify actual impact from your review – the same way that changes in a coding audit would be recorded and reported. Most importantly, feedback to the individual physician is important. And, as you perform more documentation audits, it will be important to "trend" your findings. If you do identify patterns of documentation deficiencies, it will be important to educate physicians as a group or specialty on the documentation deficiencies you have identified, as well as the impact of those findings.
By Ruthann Russo JD, MPH, RHIT |
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