Corporate Compliance

Tips for data collection and record abstraction

Healthcare Auditing Weekly, December 23, 2003

Record abstraction is probably the most difficult piece of the audit process to control; but it's perhaps you're most important. To exercise some control, make sure your data collectors have expertise in both coding and auditing. Then, have the hospital create detailed policies and procedures for this part of the audit process.

Many other issues may arise during the audit process that a hospital should clarify for its auditors. Do the following to help them:

  • Ensure that all records for the audit are pulled at the same time and stored in the same place
  • Designate a way to mark that a particular record has been reviewed so duplicate review does not occur
  • Develop a policy for handling incomplete records
  • Detail and document when a reviewer should abort review of a particular record
  • Detail and document how the reviewer should address an unexpected situation in the record (e.g., it appears documentation has been altered)
  • Detail when and the extent to which a reviewer should make comments on the record-in addition to abstracting data elements
  • Detail and document when a reviewer should request a secondary review by a physician
  • Detail when a reviewer should request a secondary review by another coding expert

     

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