Internal audits
We are in desperate need of implementing an internal audit system. I have read the Article in the most recent ACDI Journal and have developed a potential Audit tool. However, I have a few questions:
1.How do you determine which charts to audit? I of course want to audit charts with queries to ensure that the queries are compliant. However, I am also concerned about charts without queries. Our query rate has recently dipped and we have hired new staff. I want to ensure we are catching the opportunities.
2.Do you audit charts that are still concurrent? Or are you looking at them retrospectively?
3.What is an appropriate sample? Initially, I believe it will be me doing all the auditing although in the future I would love for staff to audit each other’s records. I need it to be a manageable number but also a representative sample size. We currently have 4 CDI’s (and hiring) so I am thinking that I will pick on staff member to audit per week which would provide a monthly audit of each staff member.
Thanks for your help!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
1.How do you determine which charts to audit? I of course want to audit charts with queries to ensure that the queries are compliant. However, I am also concerned about charts without queries. Our query rate has recently dipped and we have hired new staff. I want to ensure we are catching the opportunities.
2.Do you audit charts that are still concurrent? Or are you looking at them retrospectively?
3.What is an appropriate sample? Initially, I believe it will be me doing all the auditing although in the future I would love for staff to audit each other’s records. I need it to be a manageable number but also a representative sample size. We currently have 4 CDI’s (and hiring) so I am thinking that I will pick on staff member to audit per week which would provide a monthly audit of each staff member.
Thanks for your help!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
concerns. If there are concerns about query rates, might first select a
random % of cases without queries for those staff with a lower query
rate.
2 -- retrospectively, because then staff have had the FULL opportunity
to do their 'thing'.
3 -- purely a 'gut' feeling, perhaps 5% (though 10% would be better)
random sample. For me, that represents about 2 to 5 charts per month
per cds (when restricting to queried cases). If all cases, then
somewhere between 10 and 20.
When transitioning to peer to peer audits, I believe an important
factor would be to have each case reviewed by 2 peers -- allows to look
at inter-rator reliability. When significant differences, manager
should review and 'make the call'. Staff would not know whom is
conducting the reviews on their own cases, and the 2 peers would not
know whom else is looking at the specific case. Would also rotate whom
is reviewing each other month to month.
I like the idea of doing one (or X) staff per week throughout the
month, makes less of an impact / strain on the auditor's work load.
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
Vidant Medical Center, Greenville NC
DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )
Humbly, here is the report we did which includes the audit instrument used.
Cases were selected randomly using excel and were blinded. CDCI "Auditors"
were prohibited from auditing their own cases. We selected 50 concurrent
and 50 retrospective cases, and the CDCI Specialists were "blinded" named
by the season.
Your feedback is always welcome.
Kind regards,
Melanie Halpern
*Melanie Halpern, RN-BC, MBA, CCDS*
*Clinical Documentation & Coding Supervisor*
Medical Record Services
*The* University Hospital
150 Bergen Street
B Level, Room 439
Newark, NJ 07101
Office: 973.972.3236
Fax: 973.972.3562
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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Good point Don, I would like to eventually make this peer-peer. But, we only have one seasoned CDI. The other started this fall and we recently hired (not trained) 3 with plans to hire two more. Because of this rapid expansion, I REALLY want to get this process up and running but I think it will be important that I audit myself at the time being.
Thanks for the feedback!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404