Clinical Chart audit still an important tool for improving healthcare

For all healthcare organizations, an integral component of their compliance program is audit. In the current regulatory environment, healthcare providers are under greater scrutiny than ever before.

Claim rejections, claim denials and third-party defense audits create considerable financial burden for US hospitals and health systems. In order to avoid losses associated with denied inpatient claims or third-party defense audits hospitals and health systems need to pivot from denial management to denial prevention, by establishing monthly concurrent chart audit and inpatient chart review as an effective reimbursement retention strategy.

One of the common objections to establishing a monthly concurrent audit is increased initial cost. However, even when hiring one or two additional full-time staff members or enlisting consultant resources, the savings in terms of compliance and revenue opportunities typically outweigh the cost of these individuals or services.

Every revenue generating department within the hospital must properly document and record charges in order to establish control mechanisms to ensure that appropriate procedures and charging protocol are being followed.

The purpose of Concurrent Audit is verifying that charges on the detailed itemized hospital bill are accurate and that charges represent services rendered to the patient and are ordered by physician and are based upon standard hospital practices and/or nursing protocols and procedures.

A properly trained Medical Chart Auditor with a strong clinical and billing experience assisting the appropriate department managers and nursing departments with maintaining and/or developing Charging Protocols and Policies in all revenue producing departments can play a significant role in identifying, correcting and improving the charge practices within each department.

A  complete Concurrent Chart Audit should include not only precise audit details providing audit outcomes but also a detailed monthly audit statistic report to identify departments showing a trend of over charges and under charges including departmental error rates. These audit statistic reports, help to identify the reasons why the over and under charges are occurring and can further assist departments in creating a corrective action plan for resolution to prevent errors from reoccurring.

Clinical Documentation Improvement

Clinical documentation is at the core of every patient encounter. In order to be meaningful, it must be accurate, timely, and reflect the scope of services provided.

Clinical documentation improvement offers an opportunity to improve coding and maximize reimbursement. The increasing complexity of medicine has been met with a corresponding increase in complexity of medical documentation. 

Thorough, detailed documentation leads to accurate coding, and accurate coding leads to appropriate and timely claims payments for hospitals and physicians. Most importantly, accurate documentation can lead to better, more effective patient care. It can provide more detailed information to other health care providers performing subsequent care or services on patients.

Although CDI should be common in all healthcare settings, it’s often overlooked and that’s because some physicians generally don’t understand the consequences of insufficient documentation. Ideally, documentation should include the history of present illness, severity of illness, clinical treatment, which provides a wealth of information in terms of signs, symptoms, and other details of the patient’s presenting problem.

However, in reality, it’s often lacking enough detail to justify even the most basic of services rendered, including the physical exam of multiple body systems. For example, “chest pain” is clearly not as compelling as “chest pain radiating down to the neck with shortness of breath, cough, pain in the leg, and edema.”


Every medical record by every physician or nurse practitioner requires careful evaluation to compare the diagnosis and treatment with the actual complaint or injury of the patient. All healthcare organizations, in order to ensure documentation accurately reflects the patient’s severity of illness should perform a concurrent review of medical records, validate diagnosis codes, identify missing diagnosis.

Managers and Leaders

You’re probably counting value, not adding it, if you’re managing people. Only managers count value; some even reduce value by disabling those who add value. If a diamond cutter is asked to report every 15 minutes how many stones he has cut, by distracting him, his boss is subtracting value.

By contrast, leaders focus on creating value, saying: “I’d like you to handle A while I deal with B.” He or she generates value over and above that which the team creates and is as much a value-creator as his or her followers are. Leading by example and leading by enabling people are the hallmarks of action-based leadership.

Just as managers have subordinates and leaders have followers, managers create circles of power while leaders create circles of influence.

The quickest way to figure out which of the two you’re doing is to count the number of people outside your reporting hierarchy who come to you for advice. The more that do, the more likely it is that you are perceived to be a leader.

Management consists of controlling a group or a set of entities to accomplish a goal. Leadership refers to an individual’s ability to influence, motivate, and enable others to contribute toward organizational success. Influence and inspiration separate leaders from managers, not power and control.

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