Carol Schnippert: Deficit Analysis
Deficiency Analysis /Audit
Carol Schnippert
Professor Brown
HIM-1800
430791
Deficiency analysis or deficiency audits are reports generated by the Health Information Management Department in hospitals, clinics, long-term care facilities and many other medical facility that utilize either paper or electronic health records. Concurrent review and retrospective review are the two most widely used in the HIM field.
Both concurrent and retrospective review are used in order find any mistakes that might be inside the medical records. Forms like admission and discharge papers, progress and nurses notes, physician’s orders, operative, lab, and pathology reports along with accounting and insurance forms. (AACP, 2016)
Concurrent review is done on a continuous basis, either periodically throughout a patients stay or throughout the day while the patient is an inpatient. (Sayles, 2013) Retrospective review on the other hand is normally done in the HIM records department the next day after a patient has been discharged from the facility.
Health Information Technicians examines the health records for any missing documents or wrong information in the patients’ health care records. (Strife, 2009). Once any missing or incorrect information is located in the record, it’s transferred to a separate file normally labeled as an incomplete file, then flagged so the information is corrected either by the physician if signatures are required or by the other members of the staff who have the accurate information on hand to change it. All incomplete records are closely monitored to ensure they are corrected in a timely manner and are compliant with regulations that are in place at each facility.
AACP. (2016). What is Medical Auditing.
Sayles, N. B. (2013). Health Information Management Technology: An Applied Approach Fourth Edition. Chicago: AHIMA.
Strife, C. (2009, Jan 4). Health Information Management.
Carol Schnippert
Professor Brown
HIM-1800
430791
Deficiency analysis or deficiency audits are reports generated by the Health Information Management Department in hospitals, clinics, long-term care facilities and many other medical facility that utilize either paper or electronic health records. Concurrent review and retrospective review are the two most widely used in the HIM field.
Both concurrent and retrospective review are used in order find any mistakes that might be inside the medical records. Forms like admission and discharge papers, progress and nurses notes, physician’s orders, operative, lab, and pathology reports along with accounting and insurance forms. (AACP, 2016)
Concurrent review is done on a continuous basis, either periodically throughout a patients stay or throughout the day while the patient is an inpatient. (Sayles, 2013) Retrospective review on the other hand is normally done in the HIM records department the next day after a patient has been discharged from the facility.
Health Information Technicians examines the health records for any missing documents or wrong information in the patients’ health care records. (Strife, 2009). Once any missing or incorrect information is located in the record, it’s transferred to a separate file normally labeled as an incomplete file, then flagged so the information is corrected either by the physician if signatures are required or by the other members of the staff who have the accurate information on hand to change it. All incomplete records are closely monitored to ensure they are corrected in a timely manner and are compliant with regulations that are in place at each facility.
AACP. (2016). What is Medical Auditing.
Sayles, N. B. (2013). Health Information Management Technology: An Applied Approach Fourth Edition. Chicago: AHIMA.
Strife, C. (2009, Jan 4). Health Information Management.