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Auditing medical records helps reduce liability.

G Ganguli1, S Winfrey

  • 1University of Texas-Pan American, Edinburg.

Healthcare Financial Management : Journal of the Healthcare Financial Management Association
|September 6, 1990
PubMed
Summary

Internal audits assess hospital medical records departments against established standards. This process identifies deficiencies and recommends improvements, helping hospitals reduce liability risks.

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Area of Science:

  • Healthcare Administration
  • Hospital Management
  • Medical Auditing

Background:

  • Hospital medical records departments are crucial for patient care and legal compliance.
  • Accrediting organizations and internal standards guide departmental operations.
  • Ensuring departmental effectiveness is vital for hospital performance and risk management.

Purpose of the Study:

  • To evaluate the effectiveness of internal audits in hospital medical records departments.
  • To compare departmental performance against internal and external benchmarks.
  • To identify areas for improvement and risk mitigation within medical records departments.

Main Methods:

  • Conducting an internal audit of the medical records department.
  • Utilizing employee surveys to gauge departmental operations.
  • Employing direct observation and interviews for comprehensive assessment.
  • Comparing audit findings to hospital-developed standards and accrediting body benchmarks.

Main Results:

  • The internal audit identified specific deficiencies in the medical records department.
  • The audit assessed the economy and effectiveness of departmental operations.
  • Recommendations for correcting identified deficiencies were formulated.

Conclusions:

  • Internal audits are effective tools for evaluating hospital medical records departments.
  • Audits help uncover operational deficiencies and areas for improvement.
  • Implementing audit recommendations can significantly limit a hospital's liability exposure.

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