Review of medical discharge summaries and medical documentation in a metropolitan hospital: impact on diagnostic‐related groups and <scp>W</scp>eighted <scp>I</scp>nlier <scp>E</scp>quivalent <scp>S</scp>eparation

Chin, Nicholas Chun Leong; Perera, Padeepa; Roberts, AA; Nagappan, Ramesh

doi:10.1111/imj.12084

Cited by 16 publications

(15 citation statements)

References 5 publications

(8 reference statements)

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“…Chin et al (2013) also reported the need for comprehensive documentation of principal diagnosis/es, co-morbidities and their complications to enable optimal DRG and WIES allocation in a Victorian hospital.…”

Section: Australian Researchmentioning

confidence: 99%

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

Cunningham

Williamson

Robinson

et al. 2014

HIM J

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This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most appropriate External cause codes were assigned per available documentation. Comparison of the hospital data with the state-wide Victorian Admitted Episodes Database (VAED) data on frequency of use of External cause codes revealed that the index hospital, a major trauma centre, treated comparatively more falls involving steps, stairs and ladders. The hospital sample reflected lower usage, than state-wide, of unspecified External cause codes and Other specified activity codes; otherwise, there was similarity in External cause coding. A comparison of researcher and hospital codes for the falls study sample revealed differences. The ambulance report was identified as the best source of External cause information; only 50% of hospital medical records contained sufficient information for specific code assignation for all three External cause codes, mechanism of injury, place of occurrence and activity at time of injury. Whilst all medical records contained mechanism of falls injury information, 16% contained insufficient details, indicating a deficiency in medical record documentation to underpin external cause coding. This was compounded by flaws in the ICD-10-AM classification.

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Section: Australian Researchmentioning

confidence: 99%

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

Cunningham

Williamson

Robinson

et al. 2014

HIM J

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“…Accurate and explicit medical note documentation by clinicians, as well as accurate coding inclusive of all AR‐DRG classifications, are vital for precise funding reimbursement and ongoing allocations, as well as epidemiological and research purposes. Poor medical note documentation can therefore inadvertently lead to incomplete AR‐DRG coding and suboptimal funding allocation . In our study, there was a significant proportion (81%) of encounters where additional diagnoses were captured.…”

Section: Discussionmentioning

confidence: 78%

“…In 2013, Chin et al . found that 48% of their 150 general medical inpatient admissions over a 3‐month period had DRG revisions, resulting in a financing consequence of AU$142 000 …”

Section: Discussionmentioning

confidence: 99%

Weighted activity unit effect: evaluating the cost of diagnosis‐related group coding

Tan

Senko

Hughes

et al. 2020

Internal Medicine Journal

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24 Pericas JM, Corredoira J, Moreno A, García-País MJ, Falces C, Rabuñal R et al. Relationship between Enterococcus faecalis infective endocarditis and colorectal neoplasm: preliminary results from a cohort of 154 patients. Rev Esp Cardiol (Engl Ed) 2017; 70: 451-8. 25 McBride SJ, Upton A, Roberts SA. Clinical characteristics and outcomes of patients with vancomycin-susceptible Enterococcus faecalis and Enterococcus faecium bacteraemiaa five-year retrospective review. Eur J Clin Microbiol Abstract Background: Activity-based funding (ABF) is a means of healthcare reimbursement, where hospitals are allocated funding based on the number and mix of clinical activity. The ABF model is based solely on Australian refined diagnosis-related group (AR-DRG) classifications of hospital encounters. Each AR-DRG is allocated a weighted activity unit (WAU) translating to cost value to determine ongoing funding allocations for each hospital annually. Aim: We explored cost consequences of AR-DRG coding variances within our Medical Oncology department over a 6-month period. Methods: All inpatient encounters for medical oncology from 1 January to 30 June 2014 were identified and paired with actual AR-DRG coding sheets submitted by the hospital coders. Inpatient charts were manually reviewed by a Medical Oncology Registrar to capture any changes or additional AR-DRGs, which were subsequently evaluated for total WAU value variance. Applying 1 WAU = $4676 as per the 2014 Queensland model, cost consequences were calculated. Results: A total of 116 encounters was identified for 72 patients. Of 116 patients, 95 (81%) had additional diagnoses captured, leading to an AR-DRG and WAU change in 26 encounters. The total reimbursement variance for this period was $143 404.07. Cost consequences resulted from: (i) use of abbreviations in clinical notes unable to be coded; and (ii) diagnoses not documented despite treatment delivered as per medication charts.Conclusion: Clinical note documentation ultimately determines the future funding of our healthcare system. Appropriate communication and education of medical staff and hospital coders are vital to ensure precise documentation and accurate AR-DRG coding for optimal and appropriate reimbursement in this funding model.

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“…This recommendation is supported by existing research. Quantitative research has shown that inaccurate discharge documentation leads to inaccuracies in hospital funding and increased health care costs . It also introduces serious risk and increases the chance of readmission .…”

Section: Discussionmentioning

confidence: 99%

“…Quantitative research has shown that inaccurate discharge documentation leads to inaccuracies in hospital funding and increased health care costs. 49 It also introduces serious risk and increases the chance of readmission. 50 Clinical education and feedback for junior doctors increases the satisfaction of general practitioners and long-term/aged care facilities with the quality of discharge documenta-tion 51 and is viewed positively by participating interns and consultants.…”

Section: Feasibility Of a Self-directed Clinical Auditmentioning

confidence: 99%

Interns' perceptions of performance feedback

et al. 2014

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Review of medical discharge summaries and medical documentation in a metropolitan hospital: impact on diagnostic‐related groups and Weighted Inlier Equivalent Separation

Cited by 16 publications

References 5 publications

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

Weighted activity unit effect: evaluating the cost of diagnosis‐related group coding

Interns' perceptions of performance feedback

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