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MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY
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MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY Internal Audit Plan Part 4: Internal Audit Plan
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Internal Audit Plan
Part 4: Internal Audit Plan
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 drafted a checklist for a documentation audit tool and an audit schedule. Now, you will apply your instructor’s feedback to these items to create your internal audit plan.
Follow the steps below to complete this assignment:
1. Apply your instructor’s feedback to your checklist and calendar. Create an internal audit plan that includes the following:
a. A list of all steps included to conduct an internal audit to prepare for an external audit, including descriptions of each step and rationale for the inclusion of each step
b. A one-page documentation audit tool that can assist in the evaluation of the quality of the documentation during the internal audit process
2. Determine a format that works best to share this information with the physicians.
3. To ensure your internal audit plan is 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.
4. 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.
5. 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.
6. Submit your internal audit plan to your instructor by the designated due date.
MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY
Internal Audit Plan
Part 4: Internal Audit Plan
Rubric
Level 3
Level 2
Level 1
Level 0
40-34
33-28
27-26
25-0
Internal audit steps
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.
30-25.5
25.4-21
20.9-19.5
19.4-0
Documentation audit tool
Student designed a quality documentation audit tool that contains all necessary documentation elements.
Student designed a quality documentation audit tool that contains most necessary documentation elements.
Student designed an audit tool; however, it is very brief and will not fully examine the quality of the documentation because at least half of the necessary documentation elements are missing.
Student did not design a quality documentation audit tool. More than half of the necessary documentation elements are missing.
10-8.5
8.4-7
6.9-6.5
6.4-0
Organization
All portions of both the steps and documentation tool are well-organized and easy to understand.
Most portions of both the steps and documentation tool are well-organized and easy to understand.
Half of content in the steps and documentation tool is well-organized and easy to understand.
The plan is not well-organized or easy to understand.
10-8.5
8.4-7
6.9-6.5
6.4-0
Sources
Student refers to a minimum of two credible sources.
Student includes the sources for all information in the plan.
Student refers to a minimum of two sources, but only one source is credible.
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.
5-4.25
4.24-3.50
3.49-3.25
3.24-0
Institutional Outcome
Information Literacy and Communication:
Work indicates that the student has exceeded expectations for this institutional outcome.
Information Literacy and Communication:
Work indicates that the student has successfully met expectations for this institutional outcome.
Information Literacy and Communication:
Work indicates that the student has partially met expectations for this institutional outcome.
Information Literacy and Communication:
Work indicates that the student has
not or scarcely met expectations for this institutional outcome.
Final Score:
Comments:
