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Memo for Audit of Medical Records



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    Manager, ABC HealthCare From: Mary Rehnelt Subject: Audit of Medical Records Date: 10/15/2010 Message: Recently I conducted an audit of medical records with a diagnosis of bacterial pneumonia. I was astounded to find that 65% of all the medical records researched were not supported by the proper documentation. When I questioned the staff they stated that the Medical Chief of Respiratory Medicine informed them that “there are other ways to determine bacterial pneumonia other than a lab culture”. They further stated that they were told that they should just assign the code for bacterial pneumonia.

    It may be the staff nor is the Medical Chief aware of the AHIMA Code of Ethics because of these discrepancies in the files. According to the AHIMA Code of Ethics certain principles must be strictly adhered to when updating client’s files. I found numerous violations to these codes of ethics and they are as follows: 1). Advocate, Uphold, and defend the individual’s right to privacy and the doctrine of confidentiality in the use and disclosure of information. 1. 1. Protect all confidential information to include personal, health, financial, genetic, and outcome information.

    This by law was not followed through because the charts were automatically coded for “bacterial pneumonia” without the proper medical test for the outcome of a positive result. 1. 2. Engage in social and political action that supports the protection of privacy and confidentiality, and be aware of the impact of the political arena on the health information system. Advocate for changes in policy and legislation to ensure protection of privacy and confidentiality, coding compliance, and other issues that surface as advocacy issues as well as facilitating informed participation by the public on these issues.

    This by law was not adhered to because the charts were not in compliance with regards to coding because the proper tests were not performed. 2. Put service, health and welfare of persons before self-interest and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and to the health information management profession. This was not accomplished because the proper testing was not complete for an accurate diagnosis. 2. 1. Act with integrity, behave in a trustworthy manner, elevate service to others above self-interest, and promote high standards of practice in every setting.

    This by law was broken because the method that was used with interest to the patient’s file was not “consistent by acting honestly and responsibly”. 2. 7. Take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests. This by law was in breach because the Medical Chief of Respiratory Medicine had his staff improperly code the files of his patient’s to show a possible inaccurate diagnosis. Neither the staff nor the Medical Chief acted in a professional or ethical manner when corners were cut on their clients.

    These laws were broken because: A. Incorrect codes were assigned per a physician’s instructions. B. Coding was incorrect because the documentation does not justify the procedures that were performed and billed. C. Miscoding to avoid conflict with superiors. The staff did not wish to go against the Chief with regards to coding irregularities. D. Commit in inaccurate coding practices. E. Hiding or ignoring review outcomes, such as performance data. Solutions for these codes of ethics are as follows: 1)Refuse to participate in or conceal unethical practices or procedures. )Act in a professional and ethical manner at all times. 3)Be knowledgeable about established policies and procedures for handling concerns about colleagues’ unethical behavior. These include policies and procedures created by AHIMA, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations to avoid discrepancies in files. 4)Do not participate in, condone, or be associated with dishonesty, fraud and abuse, or deception. It is my recommendation a class is held to educate the staff on the AHIMA Code of Ethics.

    Suggestions to the staff on how to avoid these issues and conflicts in the future would be to review the AHIMA Code of Ethics frequently so that they are well educated, and understand exactly what the code stands for and is all about. Also, to avoid any conflict between staff and medical professionals always seek the guidance of someone in management who can intervene, correct the situation quietly and immediately.

    References: American Health Information Management Association Code of Ethics National Association of Social Workers. Code of Ethics. ” 1999. Available at . Harman, L. B. (Ed. ). Ethical challenges in the management of health information. Gaithersburg, MD: Aspen, 2001. AHIMA Code of Ethics, 1957, 1977, 1988, and 1998. Niederpruem, Mike, MS, CAE. (2009). Code of Ethics Enhances Certification. Retrieved from http://health-information. advanceweb. com/Article/Code-of-Ethics-Enhances-Certification. aspx Center for the Study of Ethics in the Proffessions. (2008) Retrieved from http://ethics. iit. edu/indexOfCodes-2. php? key=13_375_1320

    Memo for Audit of Medical Records. (2017, Feb 18). Retrieved from

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