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| FY 2008 Audit Instructions | ||
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4. MANUAL CHART REVIEW vs. 'ELECTRONIC' (RPMS) AUDITING
For
any given patient, information on diabetes care elements and outcome measures
may be gathered in one of two ways: either by sitting down and physically
reviewing the medical record (a “manual audit”), or by performing a
computerized review using RPMS’ Diabetes Management module (an “electronic
audit”). There are pros and cons to both the manual and electronic
audits. The manual chart review is
more time consuming and is subject to both the benefits and liabilities of
requiring human judgment during the audit process.
The electronic audit is much quicker, although it requires time and
attention to careful set up before the first audit can be run.
E-audits are independent of human judgment since determinations are made
by internally programmed computer logic and are therefore more consistent than
manual audits. Their accuracy is more subject to proper PCC documentation,
coding and data entry issues. More
and more facilities are opting to perform e-audits due to the time savings and
ease of performing regular periodic audits once the initial setup has been
completed. We encourage the use of
electronic audits whenever feasible. For
facilities wishing to transition from a manual to an electronic audit, it is
imperative that they initially run simultaneous manual and e-audits to
compare the results. In theory, the
results from the manual and e-audit should be quite similar.
If the results of one or more of the audit elements are significantly
different, an investigation into the reason(s) for the difference needs to be
undertaken. Once the differences are resolved, electronic auditing then could be
used as the primary source of audit data. Section 5, beginning on this page, contains instructions for performing a manual audit. You may skip Section 5 and go directly to Section 6 if you will be performing an electronic audit.
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