MEETING ABSTRACT Open Access Clinical documentation manual audit K Fan * , M Wu, L Lau, K Lee, G Steve From 27th Patient Classification Systems International (PCSI) Working Conference Montreal, Canada. 19-22 October 2011 Introduction Preliminary audit studies in HA (Hospital Authority) hospitals have shown that diagnosis and procedure data reported in the electronic records were very accurate. However, appropriateness is as important as accuracy in clinical documentation. With the introduction of internal resource allocation based on Casemix Pay for Performance (P4P), the rele- vance of clinical documentation became apparent. Dur- ing the first year under the new P4P, there was significant improvement in clinical documentation, but large variations were observed between clusters in the extent to which specific clinical conditions were reported. In addition, clinicians were puzzled by the perverse incentives to report diagnoses and procedures entirely for financial reasons. As a consequence, HA introduced the concept of grouping standards, that is, a series of agreed upon rules that would describe when specific International Classification of Diseases codes carry significant resource implications. Objective During 2010-11, 22 grouping standards were developed through consultation with clusters and representatives of clinical specialties. In order to validate these standards, and to assess the accuracy and appropriateness of current documentation practices, a second and major manual audit was conducted. Methodology This manual audit of approximately 10,000 patient records was undertaken in January and March 2011. A stratified, randomized sample of records was extracted, with approximately 30 records applied against each of the major hospitals. Each hospital’s records were audited using a predefined methodology by staff from other clusters or Hospital Authority Head Office. Results This paper describes the manual audit and examines the implications of its results for appropriate clinical documentation. Conclusions Auditing is an important tool in ascertaining the accuracy and appropriateness of clinical documentation practices, as well as in validating existing grouping standards. Published: 19 October 2011 doi:10.1186/1472-6963-11-S1-A20 Cite this article as: Fan et al.: Clinical documentation manual audit. BMC Health Services Research 2011 11(Suppl 1):A20. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color ﬁgure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit * Correspondence: [email protected] The Hong Kong Hospital Authority, Kowloon, Hong Kong Fan et al. BMC Health Services Research 2011, 11(Suppl 1):A20 http://www.biomedcentral.com/1472-6963/11/S1/A20 © 2011 Fan et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Page 1: Clinical documentation manual audit

MEETING ABSTRACT Open Access

Clinical documentation manual auditK Fan*, M Wu, L Lau, K Lee, G Steve

From 27th Patient Classification Systems International (PCSI) Working ConferenceMontreal, Canada. 19-22 October 2011

IntroductionPreliminary audit studies in HA (Hospital Authority)hospitals have shown that diagnosis and procedure datareported in the electronic records were very accurate.However, appropriateness is as important as accuracy inclinical documentation.With the introduction of internal resource allocation

based on Casemix Pay for Performance (P4P), the rele-vance of clinical documentation became apparent. Dur-ing the first year under the new P4P, there wassignificant improvement in clinical documentation, butlarge variations were observed between clusters in theextent to which specific clinical conditions werereported.In addition, clinicians were puzzled by the perverse

incentives to report diagnoses and procedures entirelyfor financial reasons. As a consequence, HA introducedthe concept of grouping standards, that is, a series ofagreed upon rules that would describe when specificInternational Classification of Diseases codes carry sig-nificant resource implications.

ObjectiveDuring 2010-11, 22 grouping standards were developedthrough consultation with clusters and representativesof clinical specialties. In order to validate these stan-dards, and to assess the accuracy and appropriateness ofcurrent documentation practices, a second and majormanual audit was conducted.

MethodologyThis manual audit of approximately 10,000 patientrecords was undertaken in January and March 2011. Astratified, randomized sample of records was extracted,with approximately 30 records applied against each ofthe major hospitals. Each hospital’s records were audited

using a predefined methodology by staff from otherclusters or Hospital Authority Head Office.

ResultsThis paper describes the manual audit and examines theimplications of its results for appropriate clinicaldocumentation.

ConclusionsAuditing is an important tool in ascertaining the accu-racy and appropriateness of clinical documentationpractices, as well as in validating existing groupingstandards.

Published: 19 October 2011

doi:10.1186/1472-6963-11-S1-A20Cite this article as: Fan et al.: Clinical documentation manual audit. BMCHealth Services Research 2011 11(Suppl 1):A20.

Submit your next manuscript to BioMed Centraland take full advantage of:

• Convenient online submission

• Thorough peer review

• No space constraints or color figure charges

• Immediate publication on acceptance

• Inclusion in PubMed, CAS, Scopus and Google Scholar

• Research which is freely available for redistribution

Submit your manuscript at www.biomedcentral.com/submit* Correspondence: [email protected]

The Hong Kong Hospital Authority, Kowloon, Hong Kong

Fan et al. BMC Health Services Research 2011, 11(Suppl 1):A20http://www.biomedcentral.com/1472-6963/11/S1/A20

© 2011 Fan et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

mailto:[email protected]

http://creativecommons.org/licenses/by/2.0