The study of inpatient medical records on hospital deductions: An interventional study

The rate of hospital deductions is a commonly cited concern among teaching hospitals in Iran. The objective of the present study is to access the effect of the quantitative and qualitative analysis of inpatient medical records on deductions and identifying the major resources of deductions. There are currently no published interventional studies that have investigated this issue quantitatively.

In an interventional study, we reviewed all the 192 patient's medical records (PMRs) for any documentation errors, to determine the rate of deductions. We conducted a pilot of 30 cases prior to the actual survey. Nonprobability-based consecutive sampling was used. The main study was conducted in three phases: 1. Primary evaluation; 2. Training, performance of intervention and corrective actions; and 3. Final assessment. Comprehensive assessments of medical records and follow-upof error correction were carried out systematically and according to the pre-set schedule. Pre- and post-intervention assessments were compared in order to evaluate the effect of the intervention. Data were analyzed using the SPSS-20 statistical software. Paired-sample t-test was used to compare changes in deduction scores before and after the intervention. Differences at a P value less than 0.05 were considered statistically significant.

In the initial survey of 800 PMRs, nearly one quarter (24%) (Or 192 cases) had at least one type of deduction. The three top types of deductions were Laboratory (47.9%), Medical radiation (45.3%), and Physician visit (35.9%). The results showed a 2.7- to about 36-fold lower rate of hospital deductions (average: 6.4-fold; reduction from21131 to 3285 US dollars).

All in all, the results of the present study indicated that educational interventions and quantitative and qualitative analysis of inpatient medical records are very beneficial and effective in the reduction of medical record deductions.