Audit Commission warns on poor records

The Audit Commission has called on organisations at all levels of the NHS to improve the standard of record keeping and clinical coding.

In its second annual analysis of the national clinical coding audit programme that is run as part of the Payment by Results Data Assurance Framework, the spending watchdog says that errors continue to be made in assigning activity to Healthcare Resource Groups.

The Commission says that the net financial impact of the errors is “close to zero” so there is no reason to think that trusts are trying to game the system. Instead, it says the major source of errors is poor source records.

“We are concerned at the poor quality of some medical records,” its report says. “Approximately 80% of the audit reports recorded problems with the quality of records.

“We also quantified the percentage of records judged as unsafe to audit under the NHS Connecting for Health audit methodology [and found that] some trusts have high UTA rates. At one trust, approximately 16% of records were judged UTA by the auditor."

UTA effectively means that trust bills cannot be checked against the original medical records because the information in the latter is missing, incomplete, illegible or otherwise unusable.

The analysis points out: “Poor quality records and documentation not only represent financial risks under PbR, but more importantly, may lead to significant clinical and patient safety risks. Improving the quality of records will improve the quality of patient care.”

In 2008, the Academy of Royal Medical Colleges approved the first ever standards for the structure and content of medical records.

The Audit Commission has worked with the Royal College of Physicians to introduce these and more generic medical records standards to an acute trust. A report published alongside the coding analysis says these were well received and improved both record keeping and coding.

It says trusts should now review the quality of their coding and other data and work with clinicians to improve the source material for coding. It also says trusts should seek to improve their record keeping and consider introducing the national standards.

It urges primary care trusts to ensure their local trusts take action. It also says national bodies such as CfH, the Department of Health and the Audit Commission itself should continue to monitor coding, support training and development programmes, and look for other ways to improve the situation.

The analysis did find an improvement on last year, when the average HRG error rate was 9.4%. This year it was 8.1%. Specialist trusts seem to have done best in getting their error rates down.

Link: PbR data assurance framework 2008-9: key messages from year 2 of the national clinical coding audit programme.