Audit of Clinical Documentation
Meeting Australian Coding Standards (ACS)
Requirements for Public Hospitals

Jane Foster
C...
Outline
• Eastern Health
• Creation of a documentation portfolio
• Results and recommendations of a clinical
documentation...
Outline
Eastern Health (EH) (CU)
.

• Possible pictures of new hospitals.etc.
Eastern Health (EH) (CU)
.

• Possible pictures of new hospitals.etc.
Eastern Health (EH) (CU)
.

• Possible pictures of new hospitals.etc.
Eastern Health (EH)
• Eastern Health covers the Eastern Metropolitan region of
Melbourne and includes 3 main acute hospita...
EH coding service structure
Manager Health
Information – Coding
& Casemix
(1 EFT)

Coding Coordinator
Data Management &
Bo...
Coding Coordinator -Documentation
Good quality
documentation
influences good
quality coding
Direct
feed
from
PMI

Manual
data
entry
Objectives of the audit
 Identify current documentation issues that affect
quality coded data
 Determine the financial i...
Audit sample
 All documentation queries generated for
discharges across EH between 1st January and
30th June 2013
 Total...
Methodology
 Audit sample generated from ‘HISCAT’
 Common categories for each speciality
e.g. renal impairment, sepsis
...
Documentation query categories by %
ACS 0001 Principal Diagnosis
 Multiple comorbidities listed as Pdx
 Constraints of internal electronic discharge
summary...
Time spent generating queries
Activity

Average minutes spent per query

Initial coder to process

6.5

Clinician to revie...
Overall recommendations for
clinicians
No. Recommendation
1.

Avoid listing multiple principal diagnoses. Clearly document...
Overall recommendations for
clinicians
No. Recommendation
6.

Where respiratory failure is present specify:
• Acute
• Chro...
Education for clinicians
 Documentation is appropriate from a clinical
perspective
 However also require documentation t...
Education for clinicians
Common clinical
documentation

Diagnostic information
(Meeting coding requirements)

K 6.0

High ...
Conclusions
 Documentation queries are resource intensive taking an
average of 15 minutes
 The most common type of docum...
Recommendations
 Provide targeted education to the clinical staff to ensure
documentation meets ACS at time of entry
 Re...
Jane Foster & Carly Uzkuraitis, Eastern Health - CASE STUDY : Audit of Clinical Documentation - Meeting Australian Coding ...
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Jane Foster & Carly Uzkuraitis, Eastern Health - CASE STUDY : Audit of Clinical Documentation - Meeting Australian Coding Standards (ACS) Requirements for Public Hospitals

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Jane Foster, Coding Co-ordinator Documentation Portfolio, Eastern Health and Carly Uzkuraitis, Manager Health Information Coding & Casemix, Eastern Health presented this at the 5th Annual Clinical Documentation, Coding and Analysis Conference. This event is the only case study led conference in Australia looking solely at clinical documentation, coding and analysis.

For more information, please visit http://www.healthcareconferences.com.au/clinicaldocs

Published in: Health & Medicine
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Jane Foster & Carly Uzkuraitis, Eastern Health - CASE STUDY : Audit of Clinical Documentation - Meeting Australian Coding Standards (ACS) Requirements for Public Hospitals

  1. 1. Audit of Clinical Documentation Meeting Australian Coding Standards (ACS) Requirements for Public Hospitals Jane Foster Coding Coordinator – Documentation Carly Uzkuraitis Manager Health Information - Coding and Casemix Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  2. 2. Outline • Eastern Health • Creation of a documentation portfolio • Results and recommendations of a clinical documentation audit
  3. 3. Outline
  4. 4. Eastern Health (EH) (CU) . • Possible pictures of new hospitals.etc.
  5. 5. Eastern Health (EH) (CU) . • Possible pictures of new hospitals.etc.
  6. 6. Eastern Health (EH) (CU) . • Possible pictures of new hospitals.etc.
  7. 7. Eastern Health (EH) • Eastern Health covers the Eastern Metropolitan region of Melbourne and includes 3 main acute hospitals. Campus Annual Separations Coding Service EFT Angliss 36,336 4.1 EFT Box Hill 56,511 7.0 EFT Maroondah 39,224 4.2 EFT Coding Mgt - 6.0 EFT Total 21.3 EFT 132,071
  8. 8. EH coding service structure Manager Health Information – Coding & Casemix (1 EFT) Coding Coordinator Data Management & Box Hill Hospital (.8 EFT) Coding Coordinator Auditing (1 EFT) Coding Coordinator Training & Maroondah Hospital (1 EFT) Coding Coordinator Systems and Staff Performance (.6 EFT) Coding Coordinator Education & Angliss Hospital (.8 EFT) BHH Coding Team (7.0 EFT) MH Coding Team (4.2 EFT) AH Coding Team (4.1 EFT) Coding Support Clerk (.8 EFT) Coding Support Clerk (.8 EFT) Coding Support Clerk (.6 EFT) Coding Coordinator Documentation (.7 EFT)
  9. 9. Coding Coordinator -Documentation
  10. 10. Good quality documentation influences good quality coding
  11. 11. Direct feed from PMI Manual data entry
  12. 12. Objectives of the audit  Identify current documentation issues that affect quality coded data  Determine the financial implications of documentation not meeting ACS  Develop documentation query categories  Understand time spent on queries  Reduce the number of documentation queries
  13. 13. Audit sample  All documentation queries generated for discharges across EH between 1st January and 30th June 2013  Total number of documentation queries:1,526
  14. 14. Methodology  Audit sample generated from ‘HISCAT’  Common categories for each speciality e.g. renal impairment, sepsis  WIES/funding variance determined for each speciality
  15. 15. Documentation query categories by %
  16. 16. ACS 0001 Principal Diagnosis  Multiple comorbidities listed as Pdx  Constraints of internal electronic discharge summary system  Symptoms listed instead of definitive diagnosis  No diagnosis listed (particularly short stay unit)
  17. 17. Time spent generating queries Activity Average minutes spent per query Initial coder to process 6.5 Clinician to review 3 Auditor to recode and update 4.5 Initial coder to review 1 Total time 15 minutes per query
  18. 18. Overall recommendations for clinicians No. Recommendation 1. Avoid listing multiple principal diagnoses. Clearly document ONE principal diagnosis chiefly responsible for occasioning the episode of care 2. Potassium imbalances must be documented as either: • Hypokalaemia or K↓ or low K • Hyperkalaemia or K↑ or high K 3. Where renal impairment is present specify: • Acute • Chronic • Acute on Chronic 4. Where anaemia is present specify if due to: • Chronic blood loss • Acute blood loss – link back to a procedure if relevant 5. Sodium imbalances must be documented as either: • Hyponatraemia or Na↓ or low Na • Hypernatraemia or Na↑ or high Na
  19. 19. Overall recommendations for clinicians No. Recommendation 6. Where respiratory failure is present specify: • Acute • Chronic • Acute on Chronic 7. Document urinary tract infection when it occurs and how it has been treated. 8. Where sepsis is present specify: • Localised • Generalised 9. Document urinary retention when it occurs and how it has been treated. 10. Specific blood abnormalities (thrombocytopenia, anaemia, neutropenia) must be documented.
  20. 20. Education for clinicians  Documentation is appropriate from a clinical perspective  However also require documentation that enables us to code in accordance with ACS requirements  The result is quality coded data reflective of the patient’s admission as well as funding optimisation
  21. 21. Education for clinicians Common clinical documentation Diagnostic information (Meeting coding requirements) K 6.0 High K or K↑ or hyperkalaemia Hb 90 Chronic blood loss Anaemia due to acute blood Na 129 Low Na or Na↓ or hyponatraemia Urine sample – E.coli UTI Bladder scan 650ml residual Urinary retention Platelets 18 Low platelets or thrombocytopenia
  22. 22. Conclusions  Documentation queries are resource intensive taking an average of 15 minutes  The most common type of documentation query was clarifying the principal diagnosis  Preferable to improve documentation at time of entry rather than clarifying in retrospect
  23. 23. Recommendations  Provide targeted education to the clinical staff to ensure documentation meets ACS at time of entry  Re-audit after six months to identify improvements (or otherwise) through data comparison

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