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MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY

MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY

Internal Audit Plan

Part 1: Research Summary

Course, Program, and Institutional Outcome(s) Assessed:

This assignment measures your ability to meet the following outcome(s):

  • Course outcome: Outline the general process to prepare for an external audit of clinical documentation
  • Program outcome: Evaluate the accuracy and completeness of the patient record as defined by policy, external regulations, and standards
  • Institutional outcome – Information Literacy & Communication: Utilize appropriate current technology and resources to locate and evaluate information needed to accomplish a goal, and then communicate findings in visual, written, and/or oral formats. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY

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Relevant Background Information:

Coders participate in not only coding activities but also in auditing activities.  Whether a coder is having his/her chart audited by another coder or coding supervisor or is the one completing the audits of others, it is essential that coders understand the process and rationale behind both internal and external coding audits. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY

Assessment Purpose:

To demonstrate an understanding of the steps needed to prepare for an external audit.

Assessment Directions:

Imagine you are the new HIM Manager for a physician clinic.  As you start to learn more about the clinic, you realize there is not an auditing plan in place as part of the coding compliance plan, nor is there a documentation audit tool.  You discuss with the clinic physicians the importance of internal audits as preparation for external audits.  The physicians ask you to generate a plan.  You need to determine the recommended steps to complete an internal audit and create a documentation tool as part of your internal auditing plan. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY

This first part of the assignment only asks you to conduct research to identify two credible sources you can use to complete this internal audit plan.  You will then provide the sources and a summary of each source to your instructor.  This gives you an opportunity to get your instructor’s feedback on your chosen sources before you begin writing the internal audit plan.

Follow the steps below to complete this assignment:

  1. Consider the two required parts of this internal audit plan:

Part 1: A list of all steps included to conduct an internal audit to prepare for an external audit, including descriptions of each step and rationale for the inclusion of each step

Part 2: A one-page documentation audit tool that can assist in the evaluation of the quality of the documentation during the internal audit process. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY

What specific information do you need to find in your research?

  1. Conduct research to find at least two credible sources on internal and external audits and coding documentation audit tools. These sources will serve as references for your internal audit plan.  If you need help finding credible research sources, see Step #6 below.
  2. Write a brief summary of your sources. Include the identifying information for your sources (either a link to the website, the title and publication information of a book or print article, or the article identification from the Virtual Library.)  This will ensure your instructor can find your sources if they need further review.
  3. Refer to the rubric at the end of this document.  Check your work against the rubric to make sure you have done everything you’ve been asked to do. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY
  4. Refer to the following resources for assistance with finding credible research sources. To access any resources, hold down the CTRL key and click on the link, or copy and paste the link into your web browser.
    1. Video on Using the Bryant & Stratton College Virtual Library: https://www.youtube.com/watch?v=6evc10gCQgM
    2. Video on Using EBSCO Discovery Services: http://support.ebsco.com/training/flash_videos/eds/eds.html
    3. Video on using the Virtual Library to find a book: https://www.youtube.com/watch?v=PXrmMigiqPQ 
    4. Video on using the advanced search in the Virtual Library: https://www.youtube.com/watch?v=K4nuS9ydgWc
    5. Video on finding internet sources: https://www.youtube.com/watch?v=URqxoYABg9M&list=PLTjvBp1sDk4xhYfTqhreLeEdy2JUDEJUn
    6. Video on evaluating sources: https://www.youtube.com/edit?o=U&video_id=bMNg1gq36ks

Part 2: Find a Coding Edit News Report. These can be found on AAPC, AHIMA and NCCI websites.  Review the news reports and share one with your classmates. (Make sure yours is unique to your peer’s reports for full credit) Then, answer the following questions: minimum 100 words. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY

  1. What did you learn from the news reports?  Refer to at least three specific things you learned.
  2. Why is quality documentation so important?  Provide at least two specific examples from the news reports.

MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY

Internal Audit Plan

Part 1: Research Summary

Rubric

Level 3 Level 2 Level 1 Level 0
50-42.5 42.4-35 34.9-32.5 32.4-0
Source Content The sources thoroughlyprovide the information needed to cover all parts of the assignment. The sources adequately provide the information needed to cover most parts of the assignment. The sources adequately provide the information needed to cover half of the parts of the assignment. The sources are inappropriatebecause they provide information to cover less than half of the parts of the assignment.
50-42.5 42.4-35 34.9-32.5 32.4-0
Source Credibility The sources meet all three criteria of a credible source: they have a credible author, a recent publication date, and are unbiased. The sources meet two of the three criteria of a credible source: they have a credible author, a recent publication date, and are unbiased. MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY The sources meet one of the three criteria of a credible source: they have a credible author, a recent publication date, and are unbiased. The sources do not meet any of the three they do not not have a credible author, a recent publication date, and are not unbiased.MCCG210 CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY ESSAY
Final Score: Comments: