Medical Record Management Process Improvement
Efficient Medical Record (Case Note Set) processes are essential survival strategies under PbR. The project is focused on
- Assessing current medical record management processes at the Trust. The assessment will identify best practices as well as change opportunities in improving education to clinicians and managers in PbR, clinical documentation adequacy to support clinical coding, medical record management processes, clinical coding processes, and PbR monitoring programmes.
- Analysis of:
- Existing staff roles that can be revised or modified to incorporate the functions of a comprehensive medical record management process, e.g., completeness of case note sets throughout the patients stay through discharge
- Medical record control and management processes to minimize the occurrence of missing case note sets or case note sets incomplete at the point of coding, thereby hindering the accuracy of clinical coding
- Current PbR education programmes targeted at consultants, SHOs, Junior Doctors, clinicians and managers
- Existing methods of monitoring HRG assignment and PbR performance
- Impact of current clinical content practices on clinical coding and HRG assignment
- Alternative methods of managing case note sets in all settings that could be developed or better utilized to improve clinical coding and HRG assignment