How Medical Record Audits Improve Healthcare Standards

In order to meet the standards of quality patient care and improve revenue, healthcare data in medical records have an indispensable role in patient care and clinical performance, process and risk management, and specifically legal risk management, the cause to target the focus of hospitals and external bodies involved including the Government, Private, and insurance payors to introduce strategies for record completeness and issue-specific guidelines affecting the quality of care delivery and practice revenue. Following the quality accreditation requirements, medical record auditing is a systematic examination in the process of clinical auditing to ensure data accuracy, completeness, and compliance with coding and documentation requirements, potentially helping practices fulfill the purpose. By comprehensively analyzing the details of a patient and services and ensuring compliance in records with current standards, auditing increases the value and standards of medical health record keeping, ensures adequate care delivery to patients, and ultimately paves the way for providers to uncomplicate reimbursement. Stay with us to explore the role and importance of medical record audits in maintaining quality standards in healthcare.

Medical Records In Healthcare And The Components

Medical records or healthcare data is an organized information collection of the individuals/ patients receiving hospital care. The data reflect a complete medical history and health information of individuals collected by the doctors, nurses, pharmacists, and other clinicians involved in the care process. Systematically collecting an individual's medical history and record helps patients access their data on a single platform. Meanwhile, providers also get support for accessing and analyzing patient data when needed. Medical records contain:

• A complete description of patient assessment
• Admission reasons and tests conducted
• Confirmation of test results and treatments offered after test results
• Changes in medicine, including the changing conditions for which the treatment is offered
• Documentation supporting the Most Responsible Diagnosis (MRDs), comorbidities, and interventions performed.
• Clarity of information for the condition, whether it is a complication of surgery or any other change in their diagnosis.
• Legible, consistent, and complete documentation with full dates and signatures

Why are medical records important in healthcare?

The healthcare system relies heavily on the medical records collected to identify diseases, trends, and causes to evaluate practice. Among the various example advances that accurate records serve are that if completed and correctly compiled, medical records become essential tools in patient diagnosis and care procedures, facilitate patient safety, and stabilize continuity of care. Moreover, accurate records proceeded within the organization to ensure structured communication among caregivers to stabilize care. In contrast, poor communication between different healthcare professionals causes care discontinuity and significant errors. When unable to continue care, hospitals and care providers lead the way to increased costs in terms of readmissions, lengthy patient stays, and ultimately, poor patient satisfaction and trust in the organization. Moreover, accurate and complete medical records are essential for administrative reporting and legal claims.

Medical Record Audit And Its Significance In Healthcare

A medical record audit identifies the strengths and weaknesses of the information documentation in a patient chart. In simple terms, audits in healthcare tell you what is done and what needs to be done or redid to get improvements.
Clinical audit is another name used for medical record audit to improve patient care and outcomes through a systematic analysis based on standard criteria and implementation of changes in practice if needed.

Why is a medical record audit important?

• Healthcare government bodies scrutinize medical claims, and inappropriate coding in claims leads to straight denials. Conducting audits for medical records helps providers identify and correct errors before the governmental investigational audits challenge inappropriacies.
• Audits are significant in preventing fraudulent claims, such as unnecessary claims and billing activity.
• Medical record audits help prevent undercoding and suggest ways for providers to bill appropriately for the documentation.
• Auditing also helps practices avoid using outdated or incorrect coding in claims.
• Auditing determines outliers in hand to prevent the issues of error identification when processed by payers in their claim software.
• The process also helps providers identify reimbursement-related issues and suggest ways to improve reimbursement.

What do medical auditors audit for in a patient chart?

Medical record auditors audit patient charts to monitor payment levels, peer review, and Quality Assurance and Performance Improvement procedures. The medical auditors ensure the records are detailed, complete, and accurate according to the Federal and State Laws and Regulations and ASC (Ambulatory Surgical Center) Policy.

Medical Records And Coverage Conditions:

Moreover, the medical record auditors review charts based on the coverage requirements detailed in the table below:

Medical Records Evaluation	Complete, comprehensive, and accurate records Information in each record must be used to assure quality care delivery to each patient To review a sample of active and closed medical records to ensure compliance with Federal and State Laws
Medical Record Content	Patient identification Medical history and physical examination results Pre-operative diagnostic studies (entered before surgery) Findings and operation techniques include a pathologist report on all tissues removed in the surgery process Entries related to anesthesia administration Any allergies or abnormal drug reaction Documentation of properly executed informed patient consent Discharge diagnosis
CMS Conditions for Coverage	Physicians orders for medications and biologicals Advance directive (if applicable) Anesthesia pre and post-evaluation Copy of discharge instructions Verbal orders and confirmation of verbal orders (RB&V)

Major Types of Audits In Healthcare

Internal Audits

• Conducted within the organization by internal auditors and quality officers from the different departments.
• The purpose is to evaluate the quality system to improve the quality of care delivered.
• Internal audits are used to enhance the potential of healthcare quality management systems.
• Auditing also helps practices avoid using outdated or incorrect coding in claims.
• Focus more on organizational conditions than the performance of healthcare professionals and patient outcomes.

External Audits

• These are accreditation, peer reviews, and certification anchored in QA.
• Assure compliance with minimum quality standards
• External audits assess the quality system in healthcare organizations based on specific standards

Clinical Audits

• Differ from other types of healthcare audits
• Healthcare professionals conduct clinical audits
• These types of audits represent a shift from QA to QI
• Aim to increase the ability to fulfill the quality requirements
• These audits aim to improve care, enhance performance, and prevent poor care
• Healthcare professionals work simultaneously to collect data and analyze their performance
• Providers encourage sustained improvements by applying continual audits in practice

Why should regular medical record audits be on your to-do list?

A medical record audit or auditing of a healthcare document aims to analyze the entire health information management (HIM) process. The job of a professional medical record auditor is to identify errors in claim filing, coding, and billing and to recommend corrections before document submission. Here are some of the significant reasons why you should include regular audits in your practice:
To ensure document accuracy - Medical record errors can directly impact patient care, and a provider's ignorance toward an incorrectly filed medical record necessitating a follow-up may lead the patient chart to HIPAA privacy violation. Hence, ensuring accuracy through conducting regular medical record audits is one of the significant benefits.
To ensure compliance with records - Documentation requirements vary as per the insurance payers' demands and disease identification that the providers must consider. Auditing helps your practice identify issues such as late filing or indexing that may be adjusted to ensure information is recorded following the compliance rules.
To enhance standardization - Providers working on patient charts from different locations aren't new, causing doctors difficulty accessing patient data. Regular audits help you eliminate the issues and offer a standardized system to instantly find data as it's consistently filed in the exact location and labeled the same way. Moreover, standardization also helps you to access detailed reports on certain documents.
Ensures cost effectiveness - When medical records are accurate, standardized, and compliant, healthcare practice gains strength. For example, better data processing improves patient care quality and enhances time and cost-savings.
Audits offer efficiency in documentation - Auditing offers analysis, resulting in process change. When documentation is comprehensively reviewed and verified, your practice can save time while finding opportunities and ways to streamline filling and indexing.

Some Other Benefits Of Medical Record Auditing

Auditing Encourages Effective Communication

Along with the various benefits of conducting audits in healthcare, such as error identification, to facilitate stability of care and patient safety, auditing ensures documentation is accurate and complete to maintain an effective line of communication between caregivers. In contrast, incomplete and unstructured communication between healthcare providers leads to discontinued care, resulting in errors, readmissions, increased costs, and poor patient satisfaction as it delays treatment and diagnosis.

Auditing To Improve Care Delivery

Offering quality care and patient safety has recently become an increasing consideration of professionals in healthcare. Healthcare authorities feel a deterring need to systematically analyze the care delivered and determine the areas that need improvement. Auditing in healthcare organizations is the best solution to cater to the cause, as suggested by the regulatory bodies. "Audits are a quality improvement (QA) approach" to bring change for the better.

Our Comprehensive Medical Chart Audits Ensuring Excellent Performance And Profitability

Auditing sensitive healthcare data may intimidate you, but outsourcing is always the preferable option for services that your in-house staff may lack expertise in. Trust a reliable partner such as MedsIT Nexus Medical Billing and Coding Solutions that also extends its services to offer comprehensive medical record audits. We are a competent and experienced record review company following the current industry standards to ensure your practice documentation is accurate and compliant with the current healthcare industry standards.