A review of hospital medical record audits: implications for funding and training.
This paper summarises the findings of coding audits in seven hospitals and one re-audit conducted by the Health Department of Western Australia. The accuracy of the coding in the first audits, as measured by differences in AN-DRG assignment, varied from 83% to 93%. The accuracy of the coding in the re-audited hospital increased by 6% to 94.5%. The major coding problems related to incorrect abstraction of information from the medical record, inaccurate code assignment, non-application of the Australian Coding Standards, or poor documentation. On average, these coding problems resulted in a loss of nearly $400,000 per hospital per year in the surveyed hospitals.
Stevens
S
S
Health Department of Western Australia.
Unwin
C E
CE
Codde
J P
JP
D000043:Abstracting and Indexing / Q000592:standards*; D003625:Data Collection; D003953:Diagnosis-Related Groups / Q000145:classification; D004194:Disease / Q000145:classification; D017598:Efficiency, Organizational; D005568:Forms and Records Control / Q000592:standards; D006777:Hospitals, Proprietary / Q000191:economics / Q000458:organization & administration / Q000592:standards; D006779:Hospitals, Public / Q000191:economics / Q000458:organization & administration / Q000592:standards; D006801:Humans; D008499:Medical Records / Q000145:classification*; D008500:Medical Records Department, Hospital / Q000592:standards*; D011786:Quality Control; D014904:Western Australia