Physician involvement enhances coding accuracy to ensure national standards: an initiative to improve awareness among new junior trainees

Nallasivan, Subramanian; Gillott, T.; Kamath, Sudha D.; Blow, L; Goddard, V

doi:10.4997/jrcpe.2011.220

Cited by 12 publications

(5 citation statements)

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“…23 O'Brien found that a quality assurance review was strengthened by relevant notices and reminders which were displayed around the clinic. 26 Nallasivan emphasised the role of physician engagement and awareness about patient safety risk and the financial impact of miscoding to enhance physician chart documentation behaviour. 27 Farzandipour et al indicated that the compilation of high quality medical records relies not only on changing physician's behaviour, it also requires the support of medical record committees.…”

Section: Discussionmentioning

confidence: 99%

“…[24][25][26][27][28][29][30][31][32] Healthcare practitioners are simply the most visible in the documentation process. High-quality medical records are more likely when healthcare practitioners, health information management M Farzandipour, Z Meidani, F Rangraz Jeddi, H Gilasi, L Shokrizadeh Arani, E Fakharian, B Saddik professionals and organisation/administrators work together, acting as a 'documentation triangle'.…”

Section: Shared Responsibilitymentioning

confidence: 99%

See 1 more Smart Citation

A pilot study of the impact of an educational intervention aimed at improving medical record documentation

Farzandipour¹,

Meidani²,

F³

et al. 2013

J R Coll Physicians Edinb

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Section: Discussionmentioning

confidence: 99%

Section: Shared Responsibilitymentioning

confidence: 99%

A pilot study of the impact of an educational intervention aimed at improving medical record documentation

Farzandipour¹,

Meidani²,

F³

et al. 2013

J R Coll Physicians Edinb

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“…Achieving improvements in physician documentation is a complex process, requiring the active support of stakeholders and the implementation of systems that can adapt to existing workflows’ demands (McGinn et al , 2011). Physicians’ participation in the improvement process and their awareness of the negative impact of incomplete documentation can effectively enhance their documentation behavior (Nallasivan et al , 2011). Therefore, before developing the proposed system, all stakeholders should be involved in refining the documentation and deficiency elimination processes, and establishing new standards and principles of documentation.…”

Section: Discussionmentioning

confidence: 99%

Determining the requirements of a medical records electronic deficiency management system: a mixed-method study

Salmanizadeh

Ameri

Ahmadian

et al. 2022

RMJ

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Purpose Despite the presence of electronic medical records systems, traditional paper-based methods are often used in many countries to document data and eliminate medical record deficiencies. These methods waste patient and hospital resources. The purpose of this study is to evaluate the traditional deficiency management system and determine the requirements of an electronic deficiency management system in settings that currently use paper records alongside electronic hospital information systems. Design/methodology/approach This mixed-method study was performed in three phases. First, the traditional process of medical records deficiency management was qualitatively evaluated. Second, the accuracy of identifying deficiencies by the traditional and redesigned checklists was compared. Third, the requirements for an electronic deficiency management system were discussed in focus group sessions. Findings Problems in the traditional system include inadequate guidelines, incomplete procedures for evaluating sheets and subsequent delays in activities. Problems also included the omission of some vital data elements and a lack of feedback about the documentation deficiencies of each documenter. There was a significant difference between the mean number of deficiencies identified by traditional and redesigned checklists (p < 0.0001). The authors proposed an electronic deficiency management system based on redesigned checklists with improved functionalities such as discriminating deficiencies based on the documenter’s role, providing systematic feedback and generating automatic reports. Originality/value Previous studies only examined the positive effect of audit and feedback methods to enhance the documentation of data elements in electronic and paper medical records. The authors propose an electronic deficiency management system for medical records to solve those problems. Health-care policymakers, hospital managers and health information systems developers can use the proposed system to manage deficiencies and improve medical records documentation.

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“…Pines indicated that after implementation of incentive method, chart documentation increased significantly from 2.86 and 3.04 to 3.31, and this improvement was maintained 3 months after the plan (9). Another study emphasized the role of physician engagement and awareness about patient safety risk and financial impact of miscoding to enhance physician chart documentation behavior (24). …”

Section: Discussionmentioning

confidence: 99%

The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

Davaridolatabadi¹,

Sadoughi²,

Meidani³

et al. 2013

Acta Inform Med

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Introduction:Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since physicians play a crucial role in medical record documentation, the researchers intend to examine the effect of educational intervention on physicians’ performance and knowledge about principles of medical diagnosis recording among residents in Hormozgan University of Medical Sciences(HUMS).Methods:This quasi-experimental study was conducted in 2010 on 40 specialty residents (from internal medicine, obstetrics and gynecology, pediatrics, anesthesiology and surgery specialties) in Hormozgan University of Medical Sciences. During a workshop, guidelines for recording diagnostic information related to given specialty were taught. Before and after the intervention, five medical records from each resident were selected to assess physician performance about chart documentation. Using a questionnaire, physicians’ knowledge was investigated before and after intervention. Data were analyzed through one-way ANOVA test.Results:Change in physicians’ knowledge before and after education was not statistically significant (p = 0.15). Residents’ behavior did not have statistically significant changes during three phases of the study.Conclusion:Diversity of related factors which contributes to the quality of documentation compels portfolio of strategies to enhance medical charting. Employing combination of best practice efforts including educating physicians from the beginning of internship and applying targeted strategy focus on problematic areas and existing gap may enhance physicians’ behavior about chart documentation.

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Physician involvement enhances coding accuracy to ensure national standards: an initiative to improve awareness among new junior trainees

Cited by 12 publications

References 0 publications

A pilot study of the impact of an educational intervention aimed at improving medical record documentation

A pilot study of the impact of an educational intervention aimed at improving medical record documentation

Determining the requirements of a medical records electronic deficiency management system: a mixed-method study

The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

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