The Relationship Between Medical Record Audit and Medical Coding Audit Assessment in Thailand
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Abstract
This retrospective descriptive research aims to study the relationship between the result of medical record audits (MRA) and coding audit assessments. This research is a retrospective study of the results of MRA and coding audit by the National Health Security Office (NHSO) as in-patient medical records between 1 October 2018 to 30 September 2019 of healthcare units on the Universal Coverage Scheme (UCS) registry 910 hospitals. The data are collected through systematic random sampling. Descriptive statistics and Pearson's correlation coefficient analysis are applied to analyze the data. The results show that
1. The assessment result of MRA with the highest average scores is discharged summary record (others) (M = 8.31, SD = 0.66), while the lowest result is the consultation record (M = 5.76, SD = 1.78). Overall, the average percentage is 80.57% (SD = 8.69). The assessment results of the physician's summary of diagnosis and procedures which do not differ from the summary of diagnoses and procedures in the doctor's discharge summary (summary assessment agreement: SA0) is 43.88% (SD = 12.91). The assessment result of the coder’s medical coding which does not differ from the entered diagnoses and procedure codes (code assessment agreement: CA0) is 70.98% (SD = 15.09).
2. the average percent of MRA is based on a low positive correlation with summary assessment agreement (SA0) and code assessment agreement (CA0) (r = .97, .131, p < .01), by using Pearson's correlation coefficient analysis.
The hospital should develop, educate, and increase MRA and coding audit skills in health personnel and perform internal audits on a regular and continuous basis. Both points should be supported by information technology and policies
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