MEDICAL RECORD AUDITS
Who is Looking at your Medical Information?
Who is Looking at your Medical Information? (cont.)
MEDICARE AUDITS
If It Wasnít Documented ñ It Wasnít Done!
Common Physician Documentation Problems
Vague or General Diagnosis ñ An additional descriptor or adjective would provide a more accurate diagnosis
Information in Discharge Summary not Supported in MR
Positive Test Results are not Confirmed by the Physician
Insufficient Comorbidity Documentation
Insufficient Complication Documentation
Insufficient Documentation of DX Outside the Attendingís Specialty
Procedures not Performed in OR not Captured for Coding
Effects of Coding Under APCs
What can a chart audit do for my facility?
You and Your Role -
Email: sgoethel@rwhc.com
Home Page: http://www.rwhc.com