Clinical documentation manual audit

Introduction Preliminary audit studies in HA (Hospital Authority) hospitals have shown that diagnosis and procedure data reported in the electronic records were very accurate. However, appropriateness is as important as accuracy in clinical documentation. With the introduction of internal resource allocation based on Casemix Pay for Performance (P4P), the relevance of clinical documentation became apparent. During the first year under the new P4P, there was significant improvement in clinical documentation, but large variations were observed between clusters in the extent to which specific clinical conditions were reported. In addition, clinicians were puzzled by the perverse incentives to report diagnoses and procedures entirely for financial reasons. As a consequence, HA introduced the concept of grouping standards, that is, a series of agreed upon rules that would describe when specific International Classification of Diseases codes carry significant resource implications.