Re-Engineering Data Processing Workflow to Automate Abbreviations Audit of Clinical Documentation.

Area of Science:

• Healthcare Administration
• Clinical Documentation Improvement
• Health Informatics

Background:

• Quarterly audits of clinical case notes are performed at KK Women's and Children's Hospital (KKH) to ensure compliance with approved acronym usage.
• The current audit process is manual, involving the retrieval of both hardcopy and electronic case notes for referencing against a list of approved abbreviations by clinical coders.
• This manual approach is time-consuming and prone to human error, potentially limiting audit coverage.

Purpose of the Study:

• To re-engineer the clinical case notes audit process for improved efficiency and accuracy.
• To leverage technology, specifically an Excel application, to streamline the referencing of approved abbreviations.
• To expand audit coverage while reducing reliance on manual human effort and minimizing errors.

Main Methods:

• Implementation of process re-engineering principles to redesign the audit workflow.
• Development and utilization of a custom Excel application to automate the cross-referencing of abbreviations.
• Integration of electronic and hardcopy case note retrieval for comprehensive audit data.

Main Results:

• Significant reduction in human dependency for referencing approved acronyms.
• Demonstrated decrease in errors associated with manual abbreviation checks.
• Expansion of audit coverage achieved within the existing audit cycle.
• Substantial savings in the time allocated for conducting clinical case note audits.

Conclusions:

• Process re-engineering combined with an Excel application offers an effective solution for optimizing clinical case note audits.
• The revised process enhances compliance monitoring for approved acronym usage.
• This technological integration leads to improved efficiency, accuracy, and resource allocation in healthcare documentation audits.