peer review chart audit form or format

I am looking for a format for establishing a peer review chart audit for our facility. I have some ideas what we should be looking for, just wondering if someone has a form or best practice format they would be willing to share.

Anne M. Cocchi RN, CCDS
Clinical Documentation Reviewer
John Muir Health, Concord Campus
(925) 682-8200, Ext: 22457
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Comments

  • Great article with templates in the January journal :)

    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
  • 'great' -- in spite of my contributions :) thank you Katy

    You may already have seen the article, as well as the 2 below resources .... I'd like to see what else folks will share!

    I'm also curious to hear how folks are using an auditing process and applying the results.

    I'd also point to:
    http://blogs.hcpro.com/acdis/2011/07/white-paper-audit-your-cdi-program-to-avoid-pitfalls/
    where there is a link to the white paper (or look in the CDI Journal Archives, July 2011

    and in the Forms & Tools library, Policies, Procedures, Regulations, and Job Descriptions section
    http://www.hcpro.com/acdis/forms_tools_group.cfm?topic=WS_ACD_LIB_PPJ
    scroll down to find "Butler Auditing Tool" -- which is actually a ppt presentation discussing auditing

    IMHO, a couple of keys (perhaps obvious) to approaching development of a peer audit is to make sure that one is VERY familar with the AHIMA briefs, have a written formal policy(ies) (and there are samples in the F&T library), and make sure that folks are well aware of the formal policy.

    Don
  • edited May 2016
    I also believe there are some tools in the forms and tools library on
    the ACDIS site.

    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


    "Patriotism is easy to understand in America; it means looking out for
    yourself by looking out for your country" Calvin Coolidge
  • edited May 2016
    Thank you for the suggestions. I will take advantage of the resources.

    Anne M. Cocchi RN, CCDS
    Clinical Documentation Reviewer
    John Muir Health, Concord Campus
    ext. 22457
    pgr. 920 8562
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