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Related Experiment Videos

A professional approach to record completion.

M G Wallace

    Journal (American Medical Record Association)
    |December 11, 1987
    PubMed
    Summary
    This summary is machine-generated.

    Implementing a new program significantly reduced incomplete medical records and improved billing efficiency. This initiative enhanced the Medical Record Department

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    Area of Science:

    • Health Informatics
    • Medical Record Management
    • Hospital Administration

    Background:

    • Incomplete and delinquent medical records pose significant challenges in healthcare settings.
    • Timely completion of medical records is crucial for patient care, billing, and legal compliance.
    • Housestaff in teaching hospitals are often responsible for discharge summaries, impacting record completion rates.

    Purpose of the Study:

    • To evaluate the impact of a new program on reducing incomplete and delinquent medical records.
    • To assess the effect of the program on the timeliness of ICD-9-CM code entry and accounts receivable.
    • To improve the efficiency and control of the Medical Record Department.

    Main Methods:

    • Implementation of a program involving warning letters and potential suspension for incomplete records.

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  • Monitoring of record completion rates and discharge summary dictation by housestaff.
  • Tracking of ICD-9-CM code entry timeliness and outstanding accounts due to incomplete documentation.

    • Main Results:

    • A steady decrease in incomplete and delinquent records was achieved without physician suspension.
    • Timely entry of ICD-9-CM codes into the billing system within five days of discharge.
    • Reduction in accounts outstanding due to documentation deficiencies from 5-22 days to an average of 40-50 daily.
    • Medical Record Department gained control over incomplete records, handling less than 300 daily.

    Conclusions:

    • The new program effectively reduced incomplete medical records and improved administrative processes.
    • Enhanced efficiency of the Medical Record Department led to better physician service and interdepartmental relationships.
    • Medical and hospital administration recognized the Medical Record Department as organized and effective.