Q&A: Preparing medical records for audit requests

Q: We're seeing an increase in the volume of medical record requests from external auditors. How can we ensure that the information in the records is accurate, timely, and available to meet auditors' demands?

A: The demand for the medical record and the information it contains is already considerable and will continue to grow. So, what can an organization do? There are several options including:

Implement a comprehensive clinical documentation improvement (CDI) program that places clinicians or HIM professionals on the nursing units to work collaboratively with providers to improve documentation before the patient goes home. A concurrent CDI program will allow the identification of incomplete, vague, or conflicting documentation contained in the medical record while the patient is still being treated. The goal of a concurrent CDI program is to decrease the number of retrospective queries the coders pose after the patient is discharged. A highly effective CDI program will provide an accurate reflection of the quality of care delivered by the providers to every patient as well as support the highest level of compliant reimbursement. A CDI program will be a key part of an organization’s successful transition to value-based care.

Create a point-of-care and closed-records review process that requires the caregivers to conduct reviews for The Joint Commission and CMS documentation requirements.

Develop a policy that requires the coding manager or data quality specialist to review any release of data related to coding before your staff release these reports. Also consider requiring that one of these HIM professionals attend any meetings in which coding/quality data are being discussed. This is especially beneficial in meetings where physicians are being compared to their peers in regard to infections, complications, and utilization of services. Physicians often blame the data on poor coding, which is often not the cause.

Create a quality assurance program for physician-created documentation that addresses EHR practices such as copy-and-paste, unmanaged template creation, and voice recognition errors.

For more information, see The Contemporary Guide to Health Information Management.