Auditing for Success: Part V of the Back to Basics Series
Back to Basics is a series presented by your PAHCOM National Advisory Board
If the words “medical record audit” conjures up images of high anxiety and pounding headaches this back to basics article is especially for you. For some managers having their medical records audited is a high stress event. That level of anxiety when your Practice’s reputation and sometimes your financial wellbeing hangs in the balance has reduced many managers to sweaty palmed nervous wrecks. Fortunately, it does not have to be that way. Medical record audits, also commonly referred to as chart audits, are helpful tools that can help ensure success and provide valuable insight into developmental training needs for your staff. The key is to make sure your medical records are in compliance before your Practice is audited by an external entity like CMS. Each month, take time to audit a sampling of your practice’s medical records to ensure that the information recorded in the patient’s record is accurate and complete, that the coding is appropriate and that there are no errors in the patient’s demographic information. Knowing that your Practice’s medical records are in compliance and you can prove it, puts the words “medical record audit” back in their proper place. Just another day at the office!
Understanding the purpose of the medical record will help us to better understand why auditors are so very detail oriented when they review medical records and why we, as managers, must learn to follow suit. A patient’s medical record should accurately document all services provided including a description of the services provided and list by whom. The medical record also validates your coding and billing. In short, the medical record details the patient’s treatment history with your Practice. It is absolutely essential that these records are accurate and complete. To the untrained eye, filing a report in the incorrect chart may be no cause for concern, but for auditors and well-trained managers it is a red flag. This type of error begs the questions, how many times has this happened and how has it affected patient care? Would the Provider have made a different decision regarding the course of treatment had they had the misfiled report earlier? By reviewing your patient’s medical record, you can discern trends like misfiled reports that may need to be addressed before they become larger problems for your practice.
Healthcare is one of the most regulated industries in the country. During the Public Health Emergency, we witnessed regulatory changes daily and the expectation is that our medical practices are flexible, knowledgeable and capable of comprehending the new regulation, become and maintain compliance all while preparing for the next wave of regulatory shifts. So how do we ensure our Practices are compliant? Audit the medical records. Here’s how:
Determine your focus: What will you be reviewing during your audit.
Drill down and identify specific measures be precise
Select your patient or chart population: you can choose a date range, age, gender, diagnosis types
Select your sample size: the general rule is 10% or a minimum of 20 charts
Create or choose your auditing tool: Author Jeff Duntemann famously said, “A good tool improves the way you work. A great tool improves the way you think”. Making sure you have a good tool is key here. There are many auditing tools that have been developed and can be considered “tried and true” however you may create your own. If you choose to create your own remember to keep it fair and simple. Resist the urge to skew your parameters to accommodate a particular Provider’s style or an unofficial office policy that is not in compliance with State and Federal regulations. (PAHCOM members please check the Member Library for useful auditing tools)
Collect your data: work your tool with close attention to detail. If you discover an error not related to your audit parameters, take note of it so that it will be fixed but do not start a new criteria to address the error. Make a note to fix it and move on.
Quantify your results: If this is your first audit then your results will be the benchmark and you will expect to see your staff meet or exceed this mark at each subsequent audit. If you routinely audit your Practice’s medical records, then track and trend your results. Has your staff met their benchmarks? Are there any new areas of concern or marked improvement? Remember audits are not only indicators of mistakes and errors but also prove that your staff is getting it right!
Meet with your Providers and present the results. Remember audit results are not a hammer to use to bash your staff but more like a scalpel to skillfully remove errors from medical records. For underperforming staff consider a Plan of Correction.
Audit again next month paying close attention to any staff members who needed a Plan of Correction. Remember this whole process is to ensure that our patients medical records are accurate and complete, to ensure that our billing and coding are appropriate and that our patients medical records are reflective of the quality of care provided in your office. Expect to see room for improvement then applaud the improvement.
