THE QUALITY IMPROVEMENT GUIDELINES FOR AN INTERNAL AUDIT MANAGEMENT OF THE INPATIENT MEDICAL RECORDS CODING AT VAJIRA HOSPITAL

Abstract

The purpose of this research was to study the internal audit system of medical records coding and develop the quality improvement guidelines for the internal audit management of medical records coding at Vajira hospital, including studied the satisfaction with the guidelines that have been developed. This research was a mixed method research by conducting the interview about work system and problems from 14 person of sample group who were practical operators and used that to develop the quality improvement guidelines for an internal audit management towards medical, procedure and surgical codes. After that applied the developed method to the sample group for 4 weeks and arranged a focus group discussion and assessed their satisfaction using questionnaire that consisted of 3 aspects: 1) medical record code examination 2) tools and 3) quality improvement guideline of medical record coding.

The research result found that the problem of medical record verification was performed only twice a year. It was traceability review without a clear operational guideline thus it caused errors and could not be corrected in a timely manner. The researcher had analyzed the problems and developed that guideline by designing to have a check in the routine work, once a week or 4 times a month and at the end of the month, arranged the meeting to follow up on the performance. After that did a tryout for real work and assessed their satisfaction which found that process had helped the resulted in medical record coding having an accuracy of 94.16%, an error of 5.84% and AdjRW had been changed by 0.38. Because of this, medical compensation could be charged more than current rate based on the Diagnostic Related Groups (DRGs) and the operators were satisfied with 1) medical record code examination at the greatest level (4.32±0.69), weekly  monitoring could help to be more accurate 2) supporting tool at a high level (3.50±1.05), hospital had a complete set of medical record coding manuals and 3) quality improvement guideline of medical record coding at a high level (4.01±0.68), operators had participated in development. Suggestions of this research was hospital should implement these guidelines in their practical operations, as well as analyzes the manpower rate in the area of medical record checks to improve operations and achieve maximum efficiency.