Document Detail

Review of Medical Discharge Summaries and Medical Documentation in a Metropolitan Hospital: Impact on Diagnosis Related Groups (DRGs) and Weighted Inlier Equivalent Separation (WIES).
MedLine Citation:
PMID:  23347364     Owner:  NLM     Status:  Publisher    
BACKGROUND: Accurate and comprehensive clinical documentation is crucial for effective ongoing patient care, follow-up and to optimize case mix based funding. Each Diagnostic Related Group (DRG) is assigned a "weight": leading to Weighted Inlier Equivalent Separation (WIES), a system many public and private hospitals in Australia subscribe to. AIMS: To identify the top DRGs in a general medical inpatient service, the completeness of medical discharge documentation, commonly missed co-morbidities and system related issues and subsequent impact on DRG and WIES allocation. METHODS: 150 completed discharge summaries were randomly selected from the top ten medical DRGs in our health service. From a detailed review of the clinical documentation, principal diagnoses, associated comorbidities and complications, where appropriate, the DRG and WIES were modified. RESULTS: 72 (48%) of the 150 reviewed admissions resulted in a revision of DRG and WIES equivalent to an increase of AUD 142,000. Respiratory-based DRGs generated the largest revision of DRG and WIES, while 'Cellulitis' DRG had the largest relative change. 27% of summaries reviewed necessitated a change in coding with no subsequent change in DRG allocation or WIES. Acute renal failure, anaemia and electrolyte disturbances were the most commonly underrepresented entities in clinical discharge documentation. Seven patients had their WIES downgraded. CONCLUSION: Comprehensive documentation of principal diagnosis/diagnoses, co-morbidities and their complications is imperative to optimal DRG and WIES allocation. Regular meetings between clinical and coding staff improve the quality and timeliness of medical documentation, ensure adequate communication with general practitioners and lead to appropriate funding.
Nicholas Chin; Pathiranage Perera; Alissa Roberts; Ramesh Nagappan
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2013-1-24
Journal Detail:
Title:  Internal medicine journal     Volume:  -     ISSN:  1445-5994     ISO Abbreviation:  Intern Med J     Publication Date:  2013 Jan 
Date Detail:
Created Date:  2013-1-25     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101092952     Medline TA:  Intern Med J     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Copyright Information:
© 2013 The Authors. Internal Medicine Journal © 2013 Royal Australasian College of Physicians.
Senior Medical Registrar, Acute Medicine Advanced Trainee, Department of Medicine, Maroondah Hospital, Eastern Health, Victoria, Australia.
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