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MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY
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MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY Internal Audit Plan Part 3: Audit Schedule
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Internal Audit Plan
Part 3: Audit Schedule
Course, Program, and Institutional Outcome(s) Assessed:
This assignment measures your ability to meet the following outcome(s):
· Course outcome: Outline the general process to prepare for an external audit of clinical documentation
· Program outcome: Evaluate the accuracy and completeness of the patient record as defined by policy, external regulations, and standards
· Institutional outcome – Information Literacy & Communication: Utilize appropriate current technology and resources to locate and evaluate information needed to accomplish a goal, and then communicate findings in visual, written, and/or oral formats.
Relevant Background Information:
Coders participate in not only coding activities but also in auditing activities. Whether a coder is having his/her chart audited by another coder or coding supervisor or is the one completing the audits of others, it is essential that coders understand the process and rationale behind both internal and external coding audits.
Assessment Purpose:
To demonstrate an understanding of the steps needed to prepare for an external audit.
Assessment Directions:
Imagine you are the new HIM Manager for a physician clinic. As you start to learn more about the clinic, you realize there is not an auditing plan in place as part of the coding compliance plan, nor is there a documentation audit tool. You discuss with the clinic physicians the importance of internal audits as preparation for external audits. The physicians ask you to generate a plan. You need to determine the recommended steps to complete an internal audit and create a documentation tool as part of your internal auditing plan.
You have already completed research and identified two sources to use for this assignment. Now, you will apply your instructor’s feedback to your sources and create a checklist for quality documentation audit tools. This will give you an opportunity to get your instructor’s feedback on what should be included in your documentation audit tool before you submit it as part of your internal audit plan.
Follow the steps below to complete this assignment:
1. Review your instructor’s feedback from your research summary. If necessary, conduct additional research to identify more appropriate sources.
2. Read and take good notes from your sources. As you read and take notes, consider the schedule by which charts are audited. Where in your research can you find that information?
3. Consider the information you’ve learned from your research. Create an audit schedule that identifies what charts will be audited over a six-month period of time. Determine a format that works best for the calendar. Explain why you have chosen to structure your calendar in this way.
4. To ensure your calendar and explanation are based on fact and not just your opinion or perspective, you must information from your two research sources. You may also use additional credible sources, your current textbook, or any textbooks from other courses as references.
5. Each time you refer to information gained from a source, make sure you indicate the source of the information. It is important to avoid plagiarism by giving credit to another author’s ideas. You should include the source(s) in your plan.
6. Refer to the rubric at the end of this document. Check your work against the rubric to make sure you have done everything you’ve been asked to do.
7. Submit the calendar and explanation to your instructor by the designated due date.
MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY
Internal Audit Plan
Part 3: Audit Schedule
Rubric
Level 3
Level 2
Level 1
Level 0
90-76.5
76.4-63
62.9-58.5
58.4-0
Audit Calendar and Explanation
Student generated logical and useful steps for the internal audit that will ensure a detailed audit.
Student included thorough descriptions of each step and thorough explanations of why each step was included, with numerous, specific details.
Student generated logical and useful steps for the internal audit; however, the steps will not ensure a detailed audit because a few steps are missing.
Student included adequate descriptions of each step and adequate explanations of why each step was included, with several details.
Student generated logical and useful steps for the internal audit; however, the steps will not ensure a detailed audit because at least half of the steps are missing.
Student included partial descriptions of each step and partial explanations of why each step was included, with few details.
The steps will not ensure a detailed audit because more than half of the steps are missing.
Student included minimal to no descriptions of each step and minimal to no explanations of why each step was included, with no details.
10-8.5
8.4-7
6.9-6.5
6.4-0
Sources
Student refers to a minimum of one credible source.
Student includes the sources for all information in the plan.
Student refers to a minimum of one credible source.
Student includes the sources for most (at least 75% of the) information in the plan.
Student refers to a minimum of one source, but the source is not credible.
Student includes the sources for half of the information in the plan.
Student fails to refer any sources.
Student fails to include the sources or only includes sources for less than half of the information in the plan.
Final Score:
Comments:
