MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY Internal Audit Plan Part 2: Documentation Audit Tool Checklist

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MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY

Internal Audit Plan

Part 2: Documentation Audit Tool Checklist

Course, Program, and Institutional Outcome(s) Assessed:

This assignment measures your ability to meet the following outcome(s):

· Course outcome: Outline the general process to prepare for an external audit of clinical documentation

· Program outcome: Evaluate the accuracy and completeness of the patient record as defined by policy, external regulations, and standards

· Institutional outcome – Information Literacy & Communication: Utilize appropriate current technology and resources to locate and evaluate information needed to accomplish a goal, and then communicate findings in visual, written, and/or oral formats.

Relevant Background Information:

Coders participate in not only coding activities but also in auditing activities. Whether a coder is having his/her chart audited by another coder or coding supervisor or is the one completing the audits of others, it is essential that coders understand the process and rationale behind both internal and external coding audits.

Assessment Purpose:

To demonstrate an understanding of the steps needed to prepare for an external audit.

Assessment Directions:

Imagine you are the new HIM Manager for a physician clinic. As you start to learn more about the clinic, you realize there is not an auditing plan in place as part of the coding compliance plan, nor is there a documentation audit tool. You discuss with the clinic physicians the importance of internal audits as preparation for external audits. The physicians ask you to generate a plan. You need to determine the recommended steps to complete an internal audit and create a documentation tool as part of your internal auditing plan.

You have already completed research and identified two sources to use for this assignment. Now, you will apply your instructor’s feedback to your sources and create a checklist for quality documentation audit tools. This will give you an opportunity to get your instructor’s feedback on what should be included in your documentation audit tool before you submit it as part of your internal audit plan.

Follow the steps below to complete this assignment:

1. Review your instructor’s feedback from your research summary. If necessary, conduct additional research to identify more appropriate sources.

2. Read and take good notes from your sources. As you read and take notes, consider the characteristics of a good documentation audit tool. Where in your research can you find that information?

3. Consider the information you’ve learned from your research. Create a checklist of the most important elements that should be included in a documentation audit tool for both hospital charts and physician charts. Determine a format that works best for this checklist.

4. To ensure your checklist is based on fact and not just your opinion or perspective, you must information from your two research sources. You may also use additional credible sources, your current textbook, or any textbooks from other courses as references.

5. Each time you refer to information gained from a source, make sure you indicate the source of the information. It is important to avoid plagiarism by giving credit to another author’s ideas. You should include the source(s) in your plan.

6. Refer to the rubric at the end of this document. Check your work against the rubric to make sure you have done everything you’ve been asked to do.

7. Submit the checklist to your instructor by the designated due date.

MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY

Internal Audit Plan

Part 2: Documentation Audit Tool Checklist

Rubric

Level 3

Level 2

Level 1

Level 0

90-76.5

76.4-63

62.9-58.5

58.4-0

Documentation audit tool checklist

Student included a list of all necessary documentation elements.

Student included a list of most necessary documentation elements.

Student included a list of half of the necessary documentation elements.

More than half of the necessary documentation elements are missing.

10-8.5

8.4-7

6.9-6.5

6.4-0

Sources

Student refers to a minimum of one credible source.
Student includes the sources for all information in the plan.      

Student refers to a minimum of one credible source.
Student includes the sources for most (at least 75% of the) information in the plan.      

Student refers to a minimum of one source, but the source is not credible.

Student includes the sources for half of the information in the plan.      

Student fails to refer any sources.
Student fails to include the sources or only includes sources for less than half of the information in the plan.

Final Score:

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