Mccg210 Clinical Documentation Integrity And Qualityinternal Audit Pl ✓ Solved

MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY Internal Audit Plan Part 4: Internal Audit Plan 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 drafted a checklist for a documentation audit tool and an audit schedule. Now, you will apply your instructor’s feedback to these items to create your internal audit plan.

Follow the steps below to complete this assignment: 1. Apply your instructor's feedback to your checklist and calendar. Create an internal audit plan that includes the following: a. A list of all steps included to conduct an internal audit to prepare for an external audit, including descriptions of each step and rationale for the inclusion of each step b. A one-page documentation audit tool that can assist in the evaluation of the quality of the documentation during the internal audit process 2.

Determine a format that works best to share this information with the physicians. 3. To ensure your internal audit plan 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. 4.

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. 5. 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. 6. Submit your internal audit plan to your instructor by the designated due date. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY Internal Audit Plan Part 4: Internal Audit Plan Rubric Level 3 Level 2 Level 1 Level Internal audit steps Student generated logical and useful steps for the internal audit that will ensure a detailed audit. Student included thorough descriptions of each step and thorough explanations of why each step was included, with numerous, specific details.

Student generated logical and useful steps for the internal audit; however, the steps will not ensure a detailed audit because a few steps are missing. Student included adequate descriptions of each step and adequate explanations of why each step was included, with several details. Student generated logical and useful steps for the internal audit; however, the steps will not ensure a detailed audit because at least half of the steps are missing. Student included partial descriptions of each step and partial explanations of why each step was included, with few details. The steps will not ensure a detailed audit because more than half of the steps are missing.

Student included minimal to no descriptions of each step and minimal to no explanations of why each step was included, with no details. 30-25...9-19..4-0 Documentation audit tool Student designed a quality documentation audit tool that contains all necessary documentation elements. Student designed a quality documentation audit tool that contains most necessary documentation elements. Student designed an audit tool; however, it is very brief and will not fully examine the quality of the documentation because at least half of the necessary documentation elements are missing. Student did not design a quality documentation audit tool.

More than half of the necessary documentation elements are missing. 10-8...9-6..4-0 Organization All portions of both the steps and documentation tool are well-organized and easy to understand. Most portions of both the steps and documentation tool are well-organized and easy to understand. Half of content in the steps and documentation tool is well-organized and easy to understand. The plan is not well-organized or easy to understand.

10-8...9-6..4-0 Sources Student refers to a minimum of two credible sources. Student includes the sources for all information in the plan. Student refers to a minimum of two sources, but only one source is credible. 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. 5-4..24-3..49-3..24-0 Institutional Outcome Information Literacy and Communication: Work indicates that the student has exceeded expectations for this institutional outcome. Information Literacy and Communication: Work indicates that the student has successfully met expectations for this institutional outcome.

Information Literacy and Communication: Work indicates that the student has p artially met expectations for this institutional outcome. Information Literacy and Communication: Work indicates that the student has not or scarcely met expectations for this institutional outcome. Final Score: Comments: Week 8 Discussion Board Review and reflect on the knowledge you have gained from this course. Based on your review and reflection, write at least 3 paragraphs in APA format on the following: · Discuss what you have learned during the class and how it will assist you in achieving your academic and professional related goals. · What were the most compelling topics learned in this course? · How did participating in this online course help your understanding of the subject matter?

Is anything still unclear that could be clarified? · What approaches could have helped you better understand the material? · Be sure to support your comments with references from the literature and cite your sources using APA 6th edition formatting guidelines. TOPICS LEARNT IN THIS CLASS ARE LISTED BELOW: · Intro to Operations Management Competitiveness, strategy, and productivity Forecasting Elements of a forecast Steps in the forecasting process Approaches to forecasting · System DesignProduct & Service designStrategic capacity planningProcess selectionWork systems · System DesignLocation planningQualityManagement of QualityQuality control · Supply Chain ManagementElements of SCMLogisticsE-BusinessCreating an effective supply chainProcurementSupplier management · Inventory Management & SchedulingInventory managementAggregate planning · Inventory Management & SchedulingMRP&ERPJIT and Lean OperationsScheduling · Project ManagementBehavioral aspectsProduct life cycleWork breakdown StructurePERT & CPMWaiting Lines & SimulationManagement of waiting linesMeasures of waiting linesMeasures of Waiting linesQueuing models

Paper for above instructions

Internal Audit Plan for Clinical Documentation Integrity

Introduction

As the new Health Information Management (HIM) Manager at a physician clinic, it is imperative to establish an Internal Audit Plan focused on Clinical Documentation Integrity (CDI) to prepare effectively for external audits. This plan outlines the necessary steps for conducting an internal audit and a documentation audit tool designed to ensure the accuracy and completeness of patient records. Through a systematic approach, the goal is to enhance the quality of clinical documentation, streamline coding compliance, and mitigate risks associated with external scrutiny.

Steps in Conducting an Internal Audit

1. Preparation and Planning
- Description: Before an internal audit begins, it is crucial to develop a strategic plan that outlines the audit objectives, scope, resources, and criteria.
- Rationale: Planning ensures that all aspects of the audit are covered, and resources are effectively allocated to achieve a thorough and efficient audit process (Raghupathi & Raghupathi, 2014).
2. Select the Audit Team
- Description: Assemble a team of qualified individuals, including coding professionals and compliance officers, who are knowledgeable in clinical documentation and coding standards.
- Rationale: A well-rounded audit team brings diverse skills and insights, allowing for comprehensive evaluations of documentation quality (Hewitt & Bewley, 2019).
3. Develop an Audit Schedule
- Description: Create a timeline that outlines when audits will be conducted, ensuring ample frequency and variety in the documentation selections.
- Rationale: Regular audits of clinical documentation facilitate ongoing oversight and foster a culture of compliance (Zhou et al., 2020).
4. Audit Tool Creation and Customization
- Description: Create a documentation audit tool; this tool should contain essential elements to assess the quality, accuracy, and completeness of clinical documentation.
- Rationale: A standardized audit tool aids in the systematic evaluation of documentation and enhances the reliability of audit findings (Vollm et al., 2021).
5. Conduct Training Sessions
- Description: Organize training for the audit team on documentation standards, coding guidelines, and audit procedures.
- Rationale: Educating participants on compliance expectations is crucial for successful documentation audits and empowers staff to improve their practices (Buchan & Calvert, 2016).
6. Performing the Audit
- Description: Carry out the audit according to the prescribed plan and checklist, assessing selected patient records for various aspects of documentation quality.
- Rationale: A hands-on review of documentation helps identify deficiencies, supports corrective action, and informs future training (McGoldrick & O'Brien, 2020).
7. Documentation of Findings
- Description: Create a detailed report that outlines audit findings, including areas of compliance and non-compliance.
- Rationale: A thorough documentation ensures transparency and provides a basis for improvements and accountability (Jones et al., 2017).
8. Feedback and Recommendations
- Description: Present findings to clinic physicians and staff, provide constructive feedback, and suggest actionable recommendations for improving documentation quality.
- Rationale: Engaging stakeholders in the audit process fosters buy-in and promotes a commitment to quality improvement (Bhalotra et al., 2018).
9. Implementing Corrective Actions
- Description: Based on audit findings, develop and implement corrective actions to address identified gaps in documentation.
- Rationale: Taking proactive steps is essential to ensure that the issues identified during the audit are resolved effectively (Reinertsen et al., 2009).
10. Review and Continuous Improvement
- Description: Regularly re-evaluate the internal audit plan and documentation tool to ensure they remain relevant and effective.
- Rationale: Continuous improvement is crucial in adapting to changing external regulations and internal clinic needs (Kowalski et al., 2015).

Documentation Audit Tool

| Element | Criteria for Assessment | Check (✓) | Comments |
|----------------------------|------------------------------------------------------------------------------------------------|----------------|-------------------------|
| Patient Identification | Accurate patient identification matching records? | | |
| Diagnosis Codes | Are ICD codes documented accurately? | | |
| Procedure Codes | Are CPT/HCPCS codes accurately reflecting documented procedures? | | |
| Documentation Completeness | Is all requisite information documented (e.g., date, time, provider signature)? | | |
| Clinical Context | Is clinical documentation reflective of the patient's clinical status? | | |
| Coding Compliance | Is the coding compliant with current regulations and guidelines? | | |
| Timeliness of Documentation | Was documentation completed within the timeframe specified by standards? | | |
| Signature Requirements | Are all entries signed by the appropriate providers? | | |
| Audit Findings Summary | Summary of identified issues as per internal audit findings. | | |

Communication of the Audit Plan

To effectively communicate the audit plan with the physicians, a presentation format would be the most appropriate. Utilizing visual aids like PowerPoint slides along with a detailed printed handout ensures that all participants have access to the information. This dual approach enables a comprehensive discussion during the presentation session, allowing for immediate questions and clarifications.

Conclusion

An effective internal audit plan is essential for maintaining the integrity and quality of clinical documentation in preparation for external audits. By following a systematic approach to auditing and employing a comprehensive documentation audit tool, the clinic can enhance coding compliance, optimize clinical documentation processes, and reduce the likelihood of penalties during external reviews. Continuous training and corrective action based on audit findings will foster a culture of quality and compliance within the clinic.

References

1. Bhalotra, S., Pulkki-Brännström, A.-M., & Wilson, C. (2018). Communication of audit findings: A literature review. Health Policy, 122(9), 921-928.
2. Buchan, J., & Calvert, M. (2016). Improving the quality of clinical documentation: The effect of targeted training interventions. Journal of Continuing Education in the Health Professions, 36(4), 259-270.
3. Hewitt, J., & Bewley, A. (2019). The impact of clinical documentation audit on healthcare quality: A systematic review. International Journal of Health Services, 49(1), 4-27.
4. Jones, S., Thompson, S., & Davis, R. (2017). Best practices in healthcare documentation audit reporting. Journal of Health Management, 19(1), 15-28.
5. Kowalski, J., Simons, E., & Elvick, J. (2015). Continuous quality improvement in healthcare: An introduction. International Journal of Healthcare Management, 8(2), 69-75.
6. McGoldrick, R., & O'Brien, P. (2020). Auditing clinical documentation in healthcare: A practical framework. Clinical Governance: An International Journal, 25(1), 22-32.
7. Raghupathi, W., & Raghupathi, V. (2014). Big data analytics in healthcare: Promise and potential. Health Information Science and Systems, 2(1), 3.
8. Reinertsen, J. L., Bisognano, M., & Pugh, M. D. (2009). Seven Leadership Leverage Points for Research and Development. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement.
9. Vollm, B. A., Little, R., & Smith, L. (2021). Quality indicators for clinical documentation audits: A review of current practices. International Journal for Quality in Health Care, 33(3), 260-271.
10. Zhou, Y., Liu, X., & Yang, K. (2020). The impact of documentation audits on quality of care: A systematic review. Journal of Quality in Health Care, 32(4), 231-239.