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Evaluating the adequacy of clinical documentation

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Reference no: EM13264810

Coding and Casemix Audit include:

Evaluating the adequacy of clinical documentation

Looking for missed diagnoses

Checking the accuracy of the ICD-10-AM codes assigned and consequent appropriateness of the DRG assigned

Ensuring that associated patient data elements such as, the length of stay, separation mode, continuous mechanical ventilation (CMV) hours etc are correct

Auditing Outcomes

Need for better discharge planning; care co-ordination

Timely allied health assessment and intervention

Identification of episodes that could be managed at another facility

Identification of conditions that could be managed at another time

Barriers to admission on day of surgery

Timeliness of medical imaging

Targeting Records for Audit

Target at least the following:

Records where LOS is greater than the State Average LOS, a move to an adjacent DRG

Multiday LOS and principal diagnosis is a symptom

Calculation of CMV hours

Selection of principal diagnosis in trauma episodes

Pathology or imaging suggest a diagnosis but it is not documented and/or coded

Compliance with DH Admission Policy


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Reference no: EM13264810

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