Medical Audit

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

• ???????? ??????????????
• pradit_at_health.moph.go.th

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

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

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

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

5
?????????????????? (Medical Audit)

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

6
????????????????????????? (Coding Audit)

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

7
??????????????????????????

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

8
?????????????????? (Medical Record Audit)

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

9
Generic quality screening criteria

• Length of stay, preoperative length of stay
• Discharge planning
• Medical stability of patient at discharge
• Transfusion error
• Cause of death
• Surgical time
• Nosocomial infection
• Trauma in hospital

10

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

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

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

12
ADVERSE PATIENT EVENTS

• Admission because of adverse results or
  complications of
• OPD management
• Readmission for complications or of incomplete
• management of problems on a previous admission
• Unplanned removal, injury or repair of organ or
  structure
• during surgery/invasive procedure
• Unplanned return to theatre

13

• Pathology/histology report varies significantly
  from preoperative/antemortem diagnosis
• Hospital - acquired infection
• Cardiac or respiratory arrest
• Cadiovascular accidents or acute myocardial
  infarction within 48 hours of surgical procedure,
  or pulmonary embolus at any time postoperatively

14
EMERGENCY ROOM

• patients reattending within one week of being
  discharged
• missed fractures
• injuries to patients or staff within the
  department
• deaths within department, or during transfer out
• cardiac/respiratory arrest
• patients leaving against clinical advice
• complaints

15
MEDICINE

• unplanned readmission within 30 day
• cardiac/respiratory arrest
• unplanned transfer to ICU / CCU
• transfusion/drug reaction
• hospital-acquired pressure sore
• patient staying over 30 days
• deaths form status epilepticus,diabetic
  ketoacidosis, extradural haematoma

16
OBSTETRICS AND GYNAECOLOGY

• eclampsia
• apgar score 3 or less at five minutes and
  birthweigth gt1,500 g
• maternal complication(defined locally)after
  normal delivery
• maternal readmission within 14 days of delivery
• third-degree laceration
• haemorrhage requiring transfusion

17

• unattended delivery
• unplanned return to delivery suite
• newborn injury
• neonatal convulsion within 48 hours
• stillbirth or death within unit

18

• Gynaecological include
• return to theatre within 24 hours
• urinary tract injury
• bowel injury
• Uterine perforation at suction termination
• post-operative deep - vein thrombosis
• wound dehiscence

19
SURGERY

• peri - operative deaths
• admission to intensive care
• unplanned second operation
• unplanned readmission

20
PAEDIATRICS

• Asthma
• Gastroenteritis
• Prescribing, e.g. growth hormone
• Febrile convulsions
• Urinary tract infection
• Bed wetting

21
????????????????????????????????

• DRG ????????
• ???????????? ???/??? ???????
• ??????????????? ???/??? ???????
• ?????????? ????????????????
• Dx ???? sign symptom ???
• ???????????????
• ?????????

22
????????????????????

• ?????????? 16.38
• ??????? 70.26
• ?????????????????? 23.28
• Death, refer, observe 6.04
• Chronic case 9.91
• OR ????????????? Ix ??? 31.03
• ??????????? 13.36

23
?????????????????? (Medical Record Audit)

• ?????????
• ????????????????? ???????????????????????
• Code ICD10 ??? ICD-9-CM ?????????????
• ?????????????????????????
• ????????????????????????? ????????
  ???????????
• Check list ???????????

24
?????????????????? (Medical Record Audit)

• ????????????
• ??????????????
• ?????????? ICD10 / ICD-9-CM
• ???????????????????? (?????)

25
??????????????? AUDIT

• How and by whom data will be collected
• How often to meet and how long
• What to do with the results
• The educational aspects
• What resources will be needed
• How to preserve confidentiality

26
?????????????????? (Medical Record Audit)

• ????????????????Audit
• ?????????????????????????????
• ???????????????????????
• ???????
• ????????????????
• ?????????????????????
• Admit / Discharge

27
?????????????????? (Medical Record Audit)

• ????????????????
• ??????? ICD 10 vol.1 ??? vol.3
• ??????? ICD-9-CM ?? 2000 (procedure part)
• ?????? DRG version 2.0

28
?????????????????? (Medical Record Audit)

• ??????????????
• ??????????????????
• ????????? (60 - 90 ???? ????????)
• ?????????????????????
• ??????????????????????

29
???????????????????? (Medical Record Audit)

• ??????????
• ??????????????????????
• ?????????????? ICD
• ??????????????????????????
• ????????????? ??? ?????????????????????
• ????????????????
• ?????????????????????????

30
???????????????????? (Medical Record Audit)

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

31
???????????????????? (Medical Record Audit)

• ?????????????????????? (1396 ????)
• ?????????? 77.6
• ??????????????????????????? 15.2
• ????????????????????????? 7.1

32
???????????????????? (Medical Record Audit)

• ????????????????????? 36.5 ???????
• ????????????????????????? 7.5
• ?????????? 5.4
• ???????????????????????? 4.6
• ???????????????? 4.4
• ???????????????????????? 3.8
• 14.9 ????????????????????????? DRG

33
???????????????????????

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

34
???????????????????????

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

35
?????????????????? (Medical Record Audit)

• ???????????????
• ?????????????????????????????
• Program Grouper
• ????????

36
????????????????????????????????????

• ?????
• ?????????????????????
• Summary error
• ??????????????
• ??????????????????
• ???????????? computer
• ?????????????????
• Coding error

37
????????? Chart
??????????????
??????????
??????????(ICD10) ???????????????? (ICD 9 CM)
??????? Discharge Summary
???????

??????? ???????????
???????????????? ???????????????
??????????
38
Medical Record Audit
39
???????????? AUDIT

• HN AN
• Admission date Discharge date
• Length of stay Age
• Correct (Y/N) Payer type
• ????/???????? Discharge status/type
• In MR In Com
• Correct (Y/N)
• Doctor Authentication

40
(No Transcript)
41
Summary and Coding Audit

• ???????? ????????? ?????????????? ????????????
  ?????????????
• ?????? Discharge Summary ??? ?????????????????
  Computer
• PDx ???????????????????????????????????????
  ??????
• Other Dx ????????
• Op ???????????? ???????????
  ???????????????????? PDx

42
???????????? AUDIT

• ???????
• Diagnosis in computer (List ????????????
• ?????????) ???????? ICD in computer
• Diagnosis from summary sheet
• Diagnosis from review of medical record

43
???????????? AUDIT

• ??????? ICD10 ??? ICD-9-Cm
• ?????? S ICD
• ???????????? summary sheet
• ?????? R ICD
• ????????????????????????????????

44
???????????? AUDIT

• ?????????????????????
• In COM ??? R ICD
• S ICD ??? R ICD
• ?????? R ICD ????????

45
???????????? AUDIT

• ???????????????????????????????????????????
• ??? R ICD ??????? S ICD ????????????? summary
  assessment ???? ?????? SA
• ??? 8 ??? In com R ICD ???????????? S ICD
  ?????? CA (code assessment ??? 8)
• ??? 7 ??? In com S ICD ???????????? R ICD
  ?????? CA (code assessment ??? 7)

46
???????????? AUDIT

• ??? ICD ??? In COM ??????????? R ICD ??? S ICD
  ????????????? Code Assessment ???????? CA
• ????????????
• Summary Assess
• Code Assess
• ???????????? ?????? 0

47
????????? Summary and Coding Audit

• ICD in com ???? ICD ?????????? Computer
• Dx/Op in Summary Sheet Dx/Op ??? Discharge
  Summary
• S ICD ?????????? ICD ??? Auditor ??? Dx/Op ??
  Discharge Summary
• Dx/Op From Review Dx/Op ????????????????????????
  ? Auditor
• R ICD ?????????? ICD ??? Dx/Op From Review
• SA ?????????? Dx/Op ?? Discharge Summary
  ?????????????????
• CA ???????????????????? Dx/Op ??? Coder
  ?????????????????
• Remark ???????????????????? Auditor

48
????????? Summary and Coding Audit

• ??????????? ICD in Com , S ICD, R ICD ?????? R
  ICD ????????
• ??? S ICD ?????? R ICD ?????? ??????????????????
  0 ?????? SA
• ??? S ICD ??????? R ICD ???????????????? Summary
  Assessment ?????? SA
• ??? ICD in Com ?????? R ICD ??? S ICD ??????
  ?????????????????? 0 ?????? CA
• ??? ICD in Com ?????? R ICD ?????????? S ICD ???
  8 ?? ???? CA
• ??? ICD in Com ??????? R ICD ???????????? S ICD
  ??? 7 ?? ???? CA
• ??? ICD in Com ??????? R ICD ??? S ICD
  ???????????????? Code Assessment ?????? CA

49
????????? Summary and Coding Audit

• Summary Assess ???????????????????????? Dx/Op
  ?? Discharge Summary
• Code Assess ???????????????????????? ??? Coder
• DRG in Computer DRG ????????? ICD in Computor
• Auditor ,s DRG From R ICD DRG ????????? R ICD
• RW in Computor ??? RW ????????? DRG in Computer
  
• Auditor ,s RW From R ICD ??? RW ????????? DRG
  From R ICD

50
??????????? Summary Assessment

• 0 No disagreement
• ???????????????????????????????? Dx ??? Op ??
  Discharge Summary
• 1 Ambiguous principal diagnosis
• ????????????????????? ???????? principal
  diagnosis ???????????????? Auditor

51
??????????? Summary Assessment

• 2 Incorrect Principal Diagnosis
• ???????????????????????????? ?????????
  ??????????????????
• ???????? principal diagnosis ??? specific

52
??????????? Summary Assessment

• 3 Incorrect sequencing
• Principle diagnosis and / or operative code
  ??????????? sequence ??????????

53
??????????? Summary Assessment

• 4 Incorrect other diagnosis
• ????????????????????? 2,3 ???????

54
??????????? Summary Assessment

• 5 Incorrect operation
• ????????????????????
• ?????????????????????????????

55
??????????? Summary Assessment

• 6 Terminology not the same as in ICD10 / ICD9CM
• ??????????????????????????? ICD
  ?????????????????????????????????????????? ICD

56
??????????? Summary Assessment

• 7 Unclear terminology / document
• ??????????
• ??????????? ?????
• ??????????????????????

57
??????????? Summary Assessment

• 8 Inconsistent documentation
• ??????????????????????????????? ???? ??????????
  ????? Dx ???? Op ??? discharge summary ?????????
  Auditor

58
??????????? Summary Assessment

• 9 Other problem
• ????????? ?

59
??????????? Code Assessment

• 0 No disagreement
• ????????????????????
• 1 Inappropriate use of .8 .9
• ??????????????????? ??????????????????????????????
  ????

60
??????????? Code Assessment

• 2 Coding rules not followed
• ????????????????????? ??????????????? ICD

61
??????????? Code Assessment

• 3 Unjustified additional code
• ??? code ??????????? medical record

62
??????????? Code Assessment

• 4 Missing code
• ???. ??? / ?? ?????????? (??????????? Discharge
  summary ??? )

63
??????????? Code Assessment

• 5 Other error in coding
• ??????????????? ? ????
• urinary bladder VS gall bladder
• 0233 (ventriculopleural anastomosis) VS 0234
  (ventriculoperineostomy)

64
??????????? Code Assessment

• 6 Clerical error
• ????????????
• Operation code 530 - Unilateral repair of
  inguinal hernia
• ????????????? 503 - Lobectomy of liver

65
??????????? Code Assessment

• 7 Code disagreement due to summary disagreement
• ??????? auditor ??? coder ??????? ????????? Dx /
  Op ??? auditor ?????????? doctor

66
??????????? Code Assessment

• 8 Justified modifying of code or sequence,
  or additional code
• ?????? Discharge summary ??????????????? ???.
  ??????????????????????????? ??????????????????????
  ??????

67
??????????? Code Assessment

• 9 Other problem
• ????????? ?

68
????????? AUDIT ??????

• ???????????
• Lead to DRG change ??????? (????????)
• ??????????????????????????????????
• Staff
• ???????
• ?????

69
(No Transcript)
70
????? Medical Record Audit ?????? 2

• ??????? Content ?????????????
• Check list ??? ?????????????????????? 11 ????
• ??????????? ?????????? ??????????????????

71
????????????????????????????????????

• NA (8) ??????????????? (Not Applicable)
• Miss (9) ?????????????????? ??????????????????
• No (0) ???????? ?????????????????
• Poor (1) ??? ???????????????
• Fair (2) ????? ???????????????????
• Good (3) ??????????????????
• Excellent (4) ???????? ?????????????

72
?????????????????????? 11 ????

• Physician discharge summary
• Informed consent
• History
• Physical examination
• Progress note

73
?????????????????????? 11 ????

• Operative note
• Anesthetic record
• Labour record
• Consultation record
• Rehabilitation record
• Nurses note

74
Physician discharge summary ?????

• ???????????????????????
• ????????? Ruled of ICD (??????? ??????? ???????)
• ?????????????????????????????????
• ????????? Ruled of ICD
• ??????????????????
• ???????????????????????

75
MAIN CONDITION

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

76
??????????????????????????

• 1 ?????????????????????????????????
• ??????? (Main Condition)
• ??????? (Comorbidity) ??? ??????
  ????????????????????
• ??????????????????????????????????????
  ??????????
• ????????????????????????????????? 75 ??????
  ???????
• ????????????? ?.?.???????????????????????? 1
  ?????????

77
??????????????????????????

• 1 ????????????????????????????????????
• ??????? (Complications) ?????????
  ???????????????
• ???????????????????????????????????? ????
  ????????????? ?????????????????????????????? 75
  ??????????????????? ?????????.????????????????
  ???????? 1 ?????????
• ???????? (Other Diseases) ??? ???????????????????
  ?????? ????????????????????????????????? ???????
  ?.?.???????????????????????? 1 ?????????

78
??????????????????????????

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

79
??????????

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

80
???????

• ????????????????????????? ????????????????????????
  ??
• HEAD INJURY, MULTIPLE INJURIES
• CVA, URI, UTI
• CAR ACCIDENT, MOTORCYCLE ACCIDENT
• DIABETIC FOOT
• etc.

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

• ????????????????????????????????????
• ??????????????????????????????? Admit
  ??????????????????? ????? Discharge
  ????????????????????? Admit ????????????
  ???????????????????????? ???? ??? Admit
  ??????????? Head Injury ??????????????????????
  ?????????????????????????????????????????
  Cerebral Concussion ??????????????????????????????
  ???????? ???? Cerebral Concussion

82
??????????????????????????????????

• ?????????????????????????????? ???????????????????
  ???? ????PNEUMONIA, ANEMIA, DIABETES MELLITUS
• ??????????????????????????????????????????????????
  ???????
• ?????????????????????????????????? ????
  ?????????????? ???????????????????????????????????
  ????? ???? ????????????? ??? ???????????,
  ??????????
• ???????????????????????????

83
?????????????, ????????????????

• ???????????????????? ????? ???? ?????????
  ???????????-??????????????????????????????????????
  ??????
• ?????? ??????????????????????????????????? ????
  ??????????????????????????????????????????????????
  ?????? ????????????
• ???????????????????, ????????? ?? Lab ???????
• FEVER, CHEST PAIN, ALTERATION OF CONSCIUS
• LEUKOCYTOSIS, ST-Elevated

84
?????????? physician discharge summary

• ???????????
• ???????????
• Sequence
• ????????????
• ????????

85
??????????? Physician discharge summary

• Poor ????????????????, ?????????????????,
  ???????????? Ruled
• Fair ????????? ?? Principle diagnosis w / wo
  Operative code
• Good ???????? ??????????
• Excellent ?????? Ruled ??? ICD
  (???????????????????????????)

86
?????????????????????????????????

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

87
??????????????????????????????????

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

88
???????????????????????????

• ???????????????????
• - ?????????????? (??. 4/1)
• ?????????????????????????
• - ???????????????? ??. 501 (????????)
• ??????????????? ???????????? INTERNATIONAL FORM
  OF MEDICAL CERTIFICATE OF CAUSE OF DEATH
• ?? ICD-9 ??? ICD-10

89
????????????????????????????????

• ?????????????????????
• ????????????
• ??????? 1 ??????????????????????
• 1(?)
• 1(?)
• 1(?)
• 1(?)
• ??????? 2 ????????

90
???????????????????????

• 1. ?????????????????????????
• (MODE OF DEATH)
• 2. ????????? 1 ?????????????????????????????
  ???????????????????????????????????????????
• 3. ??????????????????????????(UNDERLYING CAUSE
  OF DEATH)
• ????????????????????????? 1

91
???????????? (MODE OF DEATH)

• ???????????? ????????????????????
• ???????????????????????????
• ????????????, ????????????
• ????????????????????????
• ?????????????
• ?????????????

92
????????????
UNDERLYING CAUSE OF DEATH

• ????????????????? ????????????????????????????????
  ????????????? ?????????????????????
• ??????????????????????????????? ?????????
• ????????????????????????????????? ????
  ???????????, ??????, ??????? ????
  ??????????????????????

93
??????? 1 - ???????????????????

• 1(?) ???? (a) BRONCHOPNEUMONIA
• 1(?) ???? (b) BASAL GANGLION HEMORRHAGE
• 1(?) ???? (c) -
• 1(?) ???? (d) MALIGNANT HYPERTENSION

94
??????????? 1 - ???????????????????

• I (a) Pulmonary Edema
• (b) Pneumocystis carinii Pneumonia
• (c) AIDS
• (d) HIV infection

95
??????????? 2 - ???????????????????

• I (a) Hemoperitoneum
• (b) Rupture liver
• (c) -
• (d) Pedestrian hit by car while walking across
  a road

96
??????????? 3 - ???????????????????

• I (a) Bronchopneumonia
• (b) Brain edema
• (c) Secondary carcinoma of both frontal lobe
• (d) Carcinoma of right breast stage III

97
??????????? 4 - ???????????????????

• I (a) Septic Shock
• (b) Urinary Tract Infection, Infected Bed So
• (c) Cerebral Contusion, Intracerebral
  Hemorrhage
• (d) Pedestrian in collision by heavy transport
  
• vehicle

98
??????????? 5 - ???????????????????

• I (a) Endotracheal Tube Obstruction
• (b) Respiratory Distress Syndrome
• (c) -
• (d) Prematurity

99
Informed Consent ?????

• ??? ????? ?? (???????) ???????????????????????????
  
• ????????????????????
• ????????????????????
• ????????????
• ????
• (Option)
  
  

100
???????????????????? ??????????????? ???????????
??? ????????????????????? ?????????????????????
???????????????????????????????? ???????????????
???????????????? ?????????????????????????????
101

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

healthlink.mcw.edu/content/article/28853/972937152
.html
102
Informed consent

• Poor ?????????? ???????????? Identify
  ??????????
• Fair ??????????, Identify ??? ???????????????
  
• Good ???????? ?????????????????????
• Excellent ?????????????????????????

103
??????????????????????????????????

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

104
?????????????????????

• Chief complaint
• Details of present illness
• What
• Where
• When
• Why
• Who
• How
• Howmany

105
?????????????????????

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associate signs and symptoms

106
?????????????????????

• ???????????????????
• Tuberculosis
• Hypertension
• Diabetes mellitus
• ??????????????????????????
• Alcoholic intake
• Tobacco
• S.T.D.

107
?????????????????????

• ??????????????? ??????? ?????????
• ????????????????????????????????
• ????????????????????????
• Vaccine, growth development ??????
• ????????????????

108
History

• Poor ????? Chief complaint
• Fair ??? What Where When Why Who How
• Howmany ?????????????
• Good ???????? ???????????????????????
• ?????????????
• Excellent ????????????????

109
???????????????????

• Vital sign
• ??????????????????
• ?????????????????????????????/????? ??????????
• ??????????????
• ??????????????????????

110
Physical examination

• Poor ?????????????? complain
• Fair ??? ??????????????????? Diagnosis ???
• Good ???????? ???????????????????????????
• ????????
• Excellent ???????????? ???????????

111
Progress notes?????

• ???????????????????????????????????????????????
• ??????????????????????????????????? / ?????
• ?????????????????? Invasive Procedures
• ?????? ?? 3 ??????
• ????????????????????????????
• ???????????????????????????????????????
• S.O.A.P. format

112
Progress note

• Poor ???????? ???????????????
• Fair ???????????
• Good ??????????????????????????????????
• Excellent ?? Subjective, Objective, Assessment
• ??? Plan ??????

113
????????????????????

• Preoperative diagnosis
• Postoperative diagnosis
• ?????????????? ?????????????
• ????????????????????????
• ??????????
• ??????????
• ???????????????? ???/???? ????????????????????

114
Operative note

• Poor ???????? finding, ???? finding ??????,
• ?????? operation ??????
• Fair ????????????????????????????
• Good ?? Operative technique ??? Finding
• ??????
• Excellent ???????????

115
??????? Content ?????????
ASA Classification of physical status Class Physi
cal status I healthy, no systemic
disease II mild to moderate systemic
disease which does not limit
activities III severe systemic disturbance,
limited exercise IV constant threat to life,
at rest V moribund patient unlikely to
survive 24 hrs. E emergency operation

• Anesthetic record
• ?????????????????????????
• Techniques ??????????
• Input / output ???????????
• Patient status ??????? 2 ???????? ...

• Diagnosis ??????????? Dr.'s diagnosis

116
Anesthetic record

• Poor ?????????? ???????????????????????????????
  ??
• Fair ?????????????????????????? ?????????
• Good ??????????????????????????
  ?????????????????

117
Labour record

• Condition ?????
• Physical status
• Progress of labour
• Condition ???
• Progress of labor

118
Labour record

• Poor ?????????? ????????? ??? ???? finding
  ??????
• Fair ?????????/?????????/???????????????????
• Good ?? Operative technique ??? Finding ??????

119
Consultation record ?????

• ?????????????????????????????
• ????????????????????????????
• ??????????????????????????????
• Adjust ??? case
• ????????????????????

120
Consultation record

• Poor ????????????????? ???? ??? consult ?????
  (Adjust ??? case) ???????????????? ???????????
• Fair ?????????????
• Good ???????????????????????????????????????????
  ????
• Excellent ?????????????????

121
Rehabilitation record ?????

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

122
Rehabilitation record

• Poor ??????????????
• Fair ??????????? Rehabilitation ?????????????
• Good ?? Operative technique ??? Finding ??????
• Excellent ???????????????????

123
Nurse note helpful

• ??????????????????????????
• ????????????????????????
• Vegetative function
• ?????
• ???????
• ??????????

124
Nurse note helpful

• Poor ?????????? ????????? Initial paper
  ????????
• Fair ??????????????????????
• Good ???????????????????????????????
• Excellent ?? Subjective, Objective, Assessment
  ??? Plan ??????

125
???????????

• Full score
• ???????????????? content ??????????????????
• Sum score
• ????????????????????????
• ?????? NA Miss

126
Overall findings ( ) 1. Documentation inadequate
for meaningful review (?????????????????????????)
( ) 2. No significant medical record issue
identified (??????????????????????????) ( ) 3.
Certain issues in question, specified
(??????????????????????????????? ????)
Auditor Date .
127
????????? AUDIT ?????????

• ???????????????????????????????? Overall findings
• 1 ?????????????????????????
• 2 ??????????????????????????
• 3 ??????????????????????????????? ???? ..

128
????????? AUDIT ?????????

• ?????? Auditor ???????????????????????????????????
  ?????

?????????????????
129
The audit cycle
Plan care Implement change
Agree criteria set target standards
Evaluate information performance versus targets
Observe practice collect data
130
????? AUDIT ???????????? ?????????

• ????????????????? Summary sheet
• ???????????????? Computer ????
• Run Grouper ???
• ????????? DRG ????? 468, 469, 470, 476, 477 ???
  feedback ?????????????????????????????

131
????? AUDIT ???????????? ?????????

• ????????????????????????????????????
• ?????
• Medical record content
• Summary error
• Coding error

132
????? AUDIT ???????????? ?????????

• ????????????????????????????? ????????????????????
  ??????
• ?????????????????????????????????
• ????????? RW ???????
• ????????? RW ???????
• ??????????????? RW ????????????????????????
• ????????????????????

133
????? AUDIT ???????????? ?????????

• ??????????
• ????????? ----gt ??????????
• ???????????? ----gt ?????????????????
• Auditor ----gt ???????????????????????

134
???????????

• ????????????????????? Correct (Y/N) ????? Item
• ?????????????????????
• Summary assessment
• Code assessment
• ?????????????????????
• ?????????????? Content of Medical Record
• ????? Item ??? Content of Medical Record

135
???????????

• ??????????????? Missing
• ?????????? Overall findings
• ??? 1 ?????????
• ??? 2 ?????????
• ??? 3 ?????????

136
??????????? 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 476 Prostatic OR Procedure Unrelated to
• Principal Diagnosis (RW 2.2234) (???)

137
??????????? DRG ??????????

• DRG 477 Nonextensive OR Procedure Unrelated to
  Principal Diagnosis (RW 1.7461)

138
???????????????? ??? ?????????????????????????
(???.)
139
???????? ????? Audit ??42 ???????????????????
????? DRG ??????? 22 ??? ??????? 75.86 ????????
RW ??? ????????? ??? 31.32 ???? 47.26
(?????15.94)
140
?????????????????????????(Overall Findings)???
????????????????
141
???????? ?????????????? ????? 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
142
???????? ?????????????? ????? 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
143
???????? ????????????????????????????????? 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
144
???????? ?????????????????????????????????????
Full score (??? 29 ????) 923 Sum score (???
29 ????) 169 ????????????? 18.31
145
???????????????????????????

• ????????????????????????????????????
• ?????????????????????????????
• ???????????????????
• ?????????????????????????????
• ??????????????????????? (????????)
• Risk Management Hospital Accreditation

146
?????????????????????

• ???????????????? audit
• ????????????????????????????? audit
  ????????????????
• ????????????????????????????
• ??? 1 ???? ??? 2 auditor ??????
• ?? care map audit
• ????? care map
• ?????????? care map

147
?????????????????? (Medical Record Audit)

• ?????????????????????????? Audit
• ?????
• ??????
• ???????????????????
• ???????????????????????????????? (option)

148
???????????????????

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

149
???????????????

• 1. ??????????, ?????????????? ?????????
• 2. ?????????????????????????????
• 3. ???????????????????????????????
• Random
• High and/or low RW
• Problem case
• 4. ????????????????????????

150
???????????????

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

151
??????????????????? Audit

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