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
DISCLAIMER/CONFIDENTIAL NOTICE: This email transmission and any documents, files or previous email messages attached to it may contain information that is confidential or legally privileged. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you are hereby notified that you must not read this transmission and that any disclosure, copying, printing, distribution or use of this transmission is strictly prohibited. If you have received this transmission in error, please immediately notify the sender by telephone or return email and delete the original transmission and its attachments without reading or saving in any manner.
Anne M. Cocchi RN, CCDS
Clinical Documentation Reviewer
John Muir Health, Concord Campus
(925) 682-8200, Ext: 22457
DISCLAIMER/CONFIDENTIAL NOTICE: This email transmission and any documents, files or previous email messages attached to it may contain information that is confidential or legally privileged. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you are hereby notified that you must not read this transmission and that any disclosure, copying, printing, distribution or use of this transmission is strictly prohibited. If you have received this transmission in error, please immediately notify the sender by telephone or return email and delete the original transmission and its attachments without reading or saving in any manner.
Comments
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
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
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
Anne M. Cocchi RN, CCDS
Clinical Documentation Reviewer
John Muir Health, Concord Campus
ext. 22457
pgr. 920 8562