From: Mary Rehnelt
Subject: Audit of Medical Records
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...