Study of medical records quality audit results of hospitals in Health Service Region 5

Abstract

This research aimed to 1) analyze situations and problems of medical record audit 2) review the medical record summary by doctor 3) examine medical record coding by coders 4) compare adjusted relative weight (AdjRW) value before and after medical record audit by National Health Security office. Subjects were divided into 2 groups including 4 doctors and 2 coders for focus group analysis and 100 inpatient medical records for auditing which was audited by National Health Security office and randomly selected. The research tools were focus group questions and a medical record audit form validated by 3 experts resulting a content validity value of 1.00. The data were collected and analyzed using content analysis, frequency, percentage and Wilcoxon signed-ranks test. The results were as follows;

1.  Focus group analysis revealed the main problem of medical record audit was a heavy workload of doctors including examining patients in OPD, IPD and ARI clinic as well as administrative and hospital quality assurance. Medical record audit committee was set up as a part of medical record audit system in this hospital. The coders were responsible for selecting and checking medical record. In case the error was detected, the medical records were returned to the physicians for further amendment. The common problems from medical record audit were incomplete diagnosis summary and insufficient details on disease on the progress note. Moreover, many newly graduated doctors were lack of knowledge on criteria of each health fund.
2.  The results from medical record summary review in one hospital in health region 5 showed 72% of correct principal diagnosis and 28% of incorrect principal diagnosis which were inaccurate (25%) and unspecific (3%). Medical coding by coders from this study exhibited 86% of correct principal diagnosis coding while 14% of which were incorrect with 14% of inaccurate principal diagnosis coding.
3.  The comparison of AdjRW value before and after medical records quality audit resulted in the average AdjRW value of 2.45 (SD=2.69) and 2.33 (SD=2.47), respectively which were not significantly different (P<0.05).

            In summary, medical record audit from this study suggested that there was an inaccuracy in medical record summary and coding. Therefore, the medical record audit system needs to be improved.