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 & 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 ...

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

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

  • 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
  • Outline • Eastern Health • Creation of a documentation portfolio • Results and recommendations of a clinical documentation audit
  • Outline View slide
  • Eastern Health (EH) (CU) . • Possible pictures of new hospitals.etc. View slide
  • 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 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
  • 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)
  • 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 implications of documentation not meeting ACS  Develop documentation query categories  Understand time spent on queries  Reduce the number of documentation queries
  • Audit sample  All documentation queries generated for discharges across EH between 1st January and 30th June 2013  Total number of documentation queries:1,526
  • Methodology  Audit sample generated from ‘HISCAT’  Common categories for each speciality e.g. renal impairment, sepsis  WIES/funding variance determined for each speciality
  • Documentation query categories by %
  • 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)
  • 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
  • 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
  • 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.
  • 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
  • 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
  • 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
  • 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