Medical Record Audit

1
?????????????????? (Medical Record Audit)

• ???????
• ??????????
• ?????????
• ????????????

2
?????????????????? (Medical Record Audit)

• ?????????????????????????????????????
  ?????????????????????????????????
• Resource in hospital
• Diagnosis and treatment
• Outcome of treatment

3
?????????????????? (Medical Record Audit)

• The systematic,critical analysis of the quality
  of medical care for the patient
• The procedures for diagnosis and treatment
• The use of resources
• The resulting outcome
• Quality of life

4
?????????????????? (Medical Record Audit)

• ??????? Audit
• Coding Audit
• ??????????????????????? ??????????????
• Financial Audit
• ?????????????????????????????
• Quality of Care Audit
• ????????? Clinical practice guideline ???

5
?????????????????? (Coding Audit)

• 1. ??????? ???????????????????????????????????
• 2. ??????? ?????????????????????????????????
• 3. ??????? ?????????????? DRG
• 4. ??????? ???????????????????????????????????????
  ??????
• 5. ??????????? ????

6
??????????????????????????

• Self-education
• Planning, information on how resources are use
• Evaluate medical care
• Add medical knowledge
• ??????????????????????????

7
?????????????????? (Medical Record Audit)

• ??????????
• ????????????????????????????????????
• ??????????????
• ????????????????????????????????????

8
???????????????????

• 1. ??????????????????????
• ???????? ?.?.?./?.?.?. ??? ?.?.?.
• ??????
• ?????????????????????
• 2. ????????????????????????????????????????
• 3. ?????????

9
???????????????

• 1. ??????????, ?????????????? ?????????
• 2. ?????????????????????????????
• 3. ???????????????????????????????
• 4. ????????????????????????

10
???????????????

• 5. ??????????? ??/????? RW ???? audit
• 6. ???????????????????????? audit

11
???????????????

• 1. ??????????, ?????????????? ?????????
• 2. ?????????????????????????????
• 3. ???????????????????????????????
• 4. ????????????????????????

12

• ????????????????????????????????
• ???????????? ?????? ??????
• 1 (HCFA,U.S.A.)
• 5 (Australian coding benchmark audit)
• 40 charts per month
• ???????????? ?????????????????????????
• ???????????? ?????????????????????
• ???????????? case ?????????
• Run ??????? Grouper ??????? DRG ????? 468, 469,
  470, 476, 477

13
?????????????????????????????
1 (HCFA,U.S.A.) 5 (Australian coding
benchmark audit) 40 charts per month for smaller
hospital
14
???????????????

• 1. ??????????, ?????????????? ?????????
• 2. ?????????????????????????????
• 3. ???????????????????????????????
• 4. ????????????????????????

15
???????????????????????????????

• Random
• Good representative sample
• High and/or low RW
• For error detection
• Problem case
• For medical management

16
???????????????

• 5. ??????????? ??/????? RW ???? audit
• 6. ???????????????????????? audit

17
??????????? ??/????? RW ???? audit

• ??????????????????????? RW
• ??????????????????? audit
• Length of stay
• Type of discharge

18
(No Transcript)
19
????????? RW ???? LOSlt 1/3 WTLOS

• Los 0 day AdjRW 0.23 RW
• Los 1 day AdjRW 0.33 RW
• Los 2 days AdjRW 0.67 RW
• Los 3 days AdjRW 0.71 RW
• Los 4 days AdjRW 0.75 RW
• Los 5 days AdjRW 0.79 RW

• Los 6 days AdjRW 0.83 RW
• Los 7 days AdjRW 0.87 RW
• Los 8 days AdjRW 0.91 RW
• Los 9 days AdjRW 0.95 RW
• Los 10 days AdjRW 0.99 RW

20
?????????? ????????? ???????

• ?????? RW ??????????? LOSltWTLOS
• ?????????? AdjRW RW/WTLOSLOS

21
??????????????????? LOSgtOT (OTgt0)

• ????????? RW ??????????? LOSgtOT (OTgt0)
• ?????????????
• AdjRW RW1(RW/2/WTLOS)(LOS-OT)

22
??????? RW ?????????????

• ??????????????????? ????? LOSlt1/3 WTLOS
• ?????????/????????? ????? dischtgt1 ??? LOSltWTLOS
• ?????????????????? ????? LOSgtOT (OTgt0)

23
????????????
??? LOS gt Wtlos/3
??? RW ????
?????? RW ?????? K (??????) x RW
??? LOS lt Wtlos/3
??????????????
????????????
??? Discht 1
RW
K ?????? x RW
(RW/wtlos)x LOS
Discht ltgt 1
RW
K ?????? x RW
????? RWadj
24
???????????????????????

• Discharge summary ????? 2 ??
• ?????????????????? 77.42 74.19
• ?????????????? 50 51.04
• ???????????? DRGs 60.76 58.49

25
???????????????????????

• ?????? ????? 2 ??
• ???????????????? 26.88 17.89
• ????????????????? 43.16 38.54
• ????????????? 53.89 45.45
• ?????????????? 46.11 39.39
• ?????????????????? 48.96 50.00

26
???????????????

• 5. ??????????? ??/????? RW ???? audit
• 6. ???????????????????????? audit

27
DRG ??????????????? audit ()
28
DRG ??????????????? audit ()
29
???????????????????????? audit
30
???????????????????????? audit
??????? 1 ?????? 100 ???? AUDIT ????????
40,000,000 ??? RW ??? 15,014.47 ?????unit
???RW ????? 2,664.10 ???
??????? 2 ?????? 80 ???? AUDIT 80
??????????? 32,000,000 ??? RW ??? ????
Audit 15,014.47 ?????unit??? RW ???? Audit
????? 2,131.28 ??? RW ???????Audit 10,933.
19 ?????unit??? RW ???? Audit ????? 3,658.58 ???
( 100 ???????????)
31
?????????????????
??????? 1
32
??????? 2
33
??????????? DRG ??????????

• DRG 468 Extensive OR Procedure Unrelated to
• Principal Diagnosis (RW 3.6202)
• DRG 469 Principal Diagnosis Invalid as
  Discharge
• Diagnosis (RW 0.0000)
• DRG 470 Ungroupable (RW 0.0000)
• DRG 477 Nonextensive OR Procedure Unrelated to
  Principal Diagnosis (RW 1.7461))

34
DRG 468,469, 476,477(??????? SIP)
35
DRG 468,469,476,477
36
DRG 470 (??????? SIP)
37
DRG 470 (??????? SIP)
38
DRG 468 ??? ??.????????? SIP
39
DRG 468 ??? ??.????????? SIP
40
DRG 469
41
????????????????????????????? ()
???????????????? ????? ????????? SIP 383 29.12
Non-SIP 1251 32.36 ??? 1634 31.60
42
????????????????????????????? ()
43
??????????????????????????????????????????????
????????????????????????????????? ?? 2542
44
?????????????? Audit ?????????????????? ???????
SIP
45
?????????????????????????(Overall
Findings)??????????????????
46
Summary Assess
(0) No disagreement (1) Ambiguous
Principal Diagnosis (2) Incorrect Principal
Diagnosis (3) Incorrect Sequencing (4)
Incorrect Other Disgnosis
47
Summary Assess
(5) Incorrect Operation (6) Terminology not
the same in IC (7) Unclear terminology/document
(8) Inconsistent documentation (9) Other
problem
48
Code Assess
(0) No disagreement (1) Inappropriate use
of .8 .9 (2) Coding rules not
followed (3) Unjustified addition
code (4) Missing code
49
Code Assess
(5) Other error in coding (6) Clerical
error (7) Code disagreement due to
summary disagreement (8) Justified modifying of
code or sequence or additional code (9)
Other problem
50
??????? AUDIT ??? ????????????????
51
??????? AUDIT ??? ????????????????
52
??????? AUDIT ??? ????????????????
53
???????????????? ??? ?????????????????????????
(???.)
54
???????????????? ??? ???????????????? (???.)
55
???????????????? ??? ??????????????? (???.)
56
???????????????? ??? ???????????????? (???.)
57
???????????????? ??? ??????????????? (???.)
58
?????????????????????????(Overall Findings)???
????????????????
59
??????? AUDIT ??? ??????? ?????
60
??????? AUDIT ??? ??????? ?????
61
(No Transcript)
62
??????? AUDIT ??? ??????? ?????
63
???????????????? ??? ??????????????(???.)
64
???????????????? ??? ????????????????
65
???????????????? ??? ????????????????
66
???????????????? ??? ??????????????????
67
?????????????????????????(Overall Findings)???
????????????
68
??????? AUDIT ??? ??????? ?????
69
??????? AUDIT ??? ??????? ?????
70
??????? AUDIT ??? ??????? ?????
71
???????????????? ??? ??????????????(???.)
72
???????????????? ??? ????????????????(???.)
73
???????????????? ??? ??????????? (???.)
74
?????????????????????????(Overall Findings)???
????????????
75
???????? ????? Audit ??42 ???????????????????
????? DRG ??????? 22 ??? ??????? 75.86 ????????
RW ??? ????????? ??? 31.32 ???? 47.26
(?????15.94)
76
???????? ?????????????? ????? Audit
Summary Assess
(0) No disagreement 34.48 (1) Ambiguous
Principal Diagnosis 3.45 (2) Incorrect
Principal Diagnosis 17.24 (3) Incorrect
Sequencing 6.90 (4) Incorrect Other
Disgnosis 44.83 (5) Incorrect
Operation 34.48 (6) Terminology not the
same in ICD - (7) Unclear
terminology/document - (8) Inconsistent
documentation 10.34 (9) Other problem
3.45
77
???????? ?????????????? ????? Audit
Code Assess
(0) No disagreement 37.93 (1)
Inappropriate use of .8 .9 6.90 (2)
Coding rules not followed 20.69 (3)
Unjustified addition code 10.34 (4) Missing
code 65.52 (5) Other error in
coding 68.97 (6) Clerical error
3.45 (7) Code disagreement due to summary
disagreement 55.17 (8) Justified modifying of
code or sequence or additional code 17.24 (9)
Other problem 20.69
78
???????? ????????????????????????????????? Audit
(?????????????)
Content of Medical Record NA Miss
No Poor Fair Good Excellent Discharge
summary Dx Op 0 0 0 45
41 7 0 Discharge summary
Others 0 0 0 38 52
3 0 Informed Consent 0
69 0 31 0 0
0 History 0 0 62 24
14 0 0 Physical examination
0 10 59 17 10 3
0 Progress note 0 86
7 7 0 0 0
Operative note 45 31 14 3
3 3 0 Anaesthetic
record 45 21 0 24 10
0 0 Labour record
100 0 0 0 0 0
0 Consultation record 83 17
0 0 0 0
0 Rehabilitation record 86 14 0
0 0 0 0 Nurses
note helpful 3 17 0
79 0 0 0
79
???????? ?????????????????????????????????????
Full score (??? 29 ????) 923 Sum score (???
29 ????) 169 ????????????? 18.31
80
?????????????????????

• ???????????????? audit
• ????????????????????????????? audit
  ????????????????
• ????????????????????????????
• ??? 1 ???? ??? 2 auditor ??????

81
?????????????????????

• ?? care map audit
• ????? care map
• ?????????? care map
• ?? medical audit
• ?? clinical practice guideline 9
  ??????????????????
• ???????? national guideline clearing house
  ??????? HA
• ?????????????????????????