J Hague1, H Nichols, J Klimmeck, S Lanigan. 1. Department of Dermatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK. joannehague@doctors.org.uk
Abstract
BACKGROUND: In the UK, a Korner Medical Record (KMR) document is completed for each inpatient discharged from hospital. The number and type of medical conditions entered onto this record are used to determine the income the department will receive for that individual patient. AIMS: We set out to audit the accuracy of the KMR documentation of our dermatology ward, and to assess what impact improving these records would have on the department's income. The audit standard was that KMRs should be completed accurately and contain all of the relevant information. METHODS: KMRs from May 2005, which had been completed initially by the ward clerk, and later by the junior medical staff, were reviewed. They were then completed by the main auditor, who had received training in KMR completion from the coding department. All three sets of KMRs were reviewed by the coding officer, and their respective income calculated. RESULTS: In total, 20 patients were discharged from the dermatology ward during April 2005. The main diagnosis given for two patients was initially incorrect, and in another eight cases it could have been more accurate than was originally documented. The total number of comorbid or 'secondary' diagnoses (for all 20 patients) reported by the ward clerk was 5. Junior staff added a further 36 secondary diagnoses. The main auditor identified an additional 35 secondary diagnoses. In total, an extra pound 9211 would have been paid to the department if KMRs had been completed by the main auditor rather than the ward clerk. On an annual basis, a potential pound 110,532 would remain unclaimed if KMR completion continued to be performed by the ward clerk. CONCLUSIONS: This audit shows that KMR completion is inadequate when performed by a nonmedical practitioner. Training of medical staff in KMR completion by the coding department also significantly increases the accuracy and completeness of documentation. Dermatologists of all grades need to be aware of the importance and process of KMR completion, and routine training of medical staff by their coding department in KMR completion is recommended.
BACKGROUND: In the UK, a Korner Medical Record (KMR) document is completed for each inpatient discharged from hospital. The number and type of medical conditions entered onto this record are used to determine the income the department will receive for that individual patient. AIMS: We set out to audit the accuracy of the KMR documentation of our dermatology ward, and to assess what impact improving these records would have on the department's income. The audit standard was that KMRs should be completed accurately and contain all of the relevant information. METHODS: KMRs from May 2005, which had been completed initially by the ward clerk, and later by the junior medical staff, were reviewed. They were then completed by the main auditor, who had received training in KMR completion from the coding department. All three sets of KMRs were reviewed by the coding officer, and their respective income calculated. RESULTS: In total, 20 patients were discharged from the dermatology ward during April 2005. The main diagnosis given for two patients was initially incorrect, and in another eight cases it could have been more accurate than was originally documented. The total number of comorbid or 'secondary' diagnoses (for all 20 patients) reported by the ward clerk was 5. Junior staff added a further 36 secondary diagnoses. The main auditor identified an additional 35 secondary diagnoses. In total, an extra pound 9211 would have been paid to the department if KMRs had been completed by the main auditor rather than the ward clerk. On an annual basis, a potential pound 110,532 would remain unclaimed if KMR completion continued to be performed by the ward clerk. CONCLUSIONS: This audit shows that KMR completion is inadequate when performed by a nonmedical practitioner. Training of medical staff in KMR completion by the coding department also significantly increases the accuracy and completeness of documentation. Dermatologists of all grades need to be aware of the importance and process of KMR completion, and routine training of medical staff by their coding department in KMR completion is recommended.