How do Hospitals maintain Data Quality and Integrity?

It is important for hospitals to uphold and enforce standards of practice to ensure that the best quality of care if given to their patients. Errors in documentation may occur from time to time which is why it is important that healthcare facilities keep complete and accurate medical records and to protect the confidentiality of the medical record. Any missing data or irregularity can impact the healthcare facility and the patient in negative ways.  Health Insurance Portability and Accountability Act (HIPAA) and the American Recovery and Reinvestment Act (ARRA) monitor healthcare facilities to ensure that there are standards in place.

Here are some ways healthcare facilities maintain data quality:

Qualitative Analysis - review of the medical records for accuracy and to see if standards were met.

• ex: audits of codes by medical coders to see if treatment and care matches which the codes

Quantitative Analysis - review of the medical records for accuracy and completeness.

• ex: missing reports and/or signatures

Here are some ways healthcare facilities maintain integrity:

Concurrent Review - occurs while the patient is receiving care. Healthcare Information Management (HIM) teams and healthcare providers work together to ensure that documentation is compiled. If there are errors, it can be readily fixed.

Occurrence Screening - also known as Risk Management-Related Audit, looks for accidents and medical records that can result in a lawsuit. These types of audits are confidential and are not part of the patient's medical record

• types of accidents: lack of consent or wrong operation was performed

Retrospective Review - occurs when the patient has been discharged. This audit looks for ways a healthcare facility can improve or to identify patterns or trends that may need improvement.