The Audit Commission is calling for the structure and content of medical records to be standardised nationally to improve care and the efficiency of clinical coding.
It follows the publication of the second annual Payment by Results (PbR) data assurance framework, which shows that 12.8% of the clinical codes for diagnoses and procedures were wrong. PbR is the fixed tariff payment system which directly links the income hospitals receive with the number and case mix of patients treated.
It suggests errors continue to affect the accuracy of payments for treatments in the NHS.
The Audit Commission report, published alongside this year’s framework, makes a series of recommendations to improve the recording of medical information. About 80% of the PbR audit reports recorded problems relating to the quality of medical records and some were judged unsafe to audit.
It calls for implementation of the Royal College of Physician’s national standards. This would unify the structure and content of medical records providing much needed clarity and consistency in the documentation of episodes and care and improve the efficiency of clinical coding.
The report says: “The factors that affect coding accuracy are the same as last year. The majority relate to the need for wider clinician involvement to improve the standard of records and other source documentation, validate codes and give direction on identifying and coding co-morbidities.
“There needs to be greater local emphasis on engaging with clinicians. National guidance and support on co-morbidities is also needed.”
It adds: “Poor quality records and documentation not only represent financial risks under PbR but, more importantly, may lead to significant clinical and patient safety risks. Improving the quality of records will help improve the quality of patient care.”
There were positives from this year’s framework, with the error rate having improved from 16.5% in 2007/08.
Meanwhile, research in the BMJ reveals more of the impact that PbR has had on healthcare delivery in the NHS.
Unit costs fell more quickly where payment by results was implemented, the research says. Evidence of an association between the introduction of payment by results and growth in acute hospital activity (volume of patients treated) was also found.
There was little evidence of any change in the quality of care associated with the introduction of payment by results.
“Taken together the analysis suggests that payment by results is capable of achieving, and has in the short time since its adoption actually achieved, real changes in delivery of health care in hospitals in England,” the authors conclude.
Tags: Medical records, PBR
Am I being cynical when I read that the impetus for ’standardisation’ of records is from a statistical and financial viewpoint? Although a ceratin amount of standardisation of records is a good thing (there are ceratin basic requirements and it is easier for ‘newcomers’ to find their way around them), one should beware of ’standardisation’ as a diktat, it sterilises thought and stultifies development; improvements have always been made by INDIVIDUALS! Medical records are CLINICAL - for the benefit of CLINICIANS, primarily; there may be secoondary administrative advantages. Good record-keeping is a matter of education; certainly when electonic, the old maxim of “Rubbish in = rubbish out” applies!
Retired Orthopod