internal audits/quality checks??

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
What processes do you have in place for internal quality checks? Do you occasionally peer-review to see if charts are being queried appropriately?

My director would like me to come up with a way to check for query quality as well as make sure that we are fairly consistent (inter-reviewer reliability?)in when we query. I have a few ideas but I'm wondering what other programs do and whether you have any tools to perform this function.

Thanks!

Katy

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    We ask our internal audit team to provide a formal audit once per year. Occasionally, we work with each other and provide feedback, but this is informal.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

  • robert.hodges2robert.hodges2
    edited May 2016
    Katy,

    There are a couple of nice tools in the Forms and Tools Library on the ACDIS website. I used a couple of them as samples when we were working on the same thing here.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

  • cstukenbergcstukenberg
    edited May 2016
    I review all queries that come back whether I did them or someone else. This way it is the same person looking at them for consistency. If I have questions I will take it back to the person who wrote it. If the person who wrote it feels it did not get addressed appropriately but should have we send it back for a retro query. It is a check and balance system for the CDI and coders to see the queries and what is being responded to.
    Thanks
    Colleen

  • tiffany_susantiffany_susan
    edited May 2016

    We meet weekly and discuss multiple issues, and review 5 randomly
    selected clarifications from each staff member. We have found this to be
    invaluable as a learning tool, both on how to structure the queries and
    what is looked for in the record.
    Thank You,
    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program
    Guthrie Healthcare System
    phone: 570-887-6094
    fax: 570-887-5152
    email: tiffany_susan@guthrie.org
    " You only live once, but if you do it right, once is enough!" Mae West


  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    You may find the ACDIS white paper helpful Audit your CDI program to avoid pitfalls:
    http://www.hcpro.com/acdis/details.cfm?topic=WS_ACD_JNL&content_id=268350

    I recently gave a presentation at the NCACDIS meeting, went into more detail on some of the content of the AHIMA papers that are relevant (will try to attach) -- filter wouldn't let through, probably size of file. Have sent to Melissa & asked it to be added to the Forms & Tools.

    There is a nice tool in the AHIMA CDI Toolkit in addition to the Forms & Tools that has been mentioned.

    Don

    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation
    Vidant Medical Center, Greenville NC
    DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Thanks everyone, for all the great ideas. I will check out the tools on the website.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

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