To: John Smith
From Anne Carino
Date: May 28, 2010
Re: Audit of Medical Records
Recently I conducted an audit of medical records with a diagnosis of bacterial pneumonia. I was quite alarmed to find that 65% of all the medical records researched were not supported by the proper documentation. When I questioned the staff they stated that the Medical Cheild of Respiratory Medicine informed them that “there are other ways to determine bacterial pneumonia other than a lab culture”. They further stated that there were told that they should just assign the code for bacterial pneumonia.
According to the AHIMA Code of Ethics certain principles need to be strictly adhered ...view middle of the document...
2.1. Act with integrity, behave in a trustworthy manner, elevate service to others above self-interest, and promote high standards of practice in every setting.
This by law was broken because the practice that was used with regards to the patient’s file was not “consistent by acting honestly and responsibly.
2.7. Take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.
This by law was discarded by the Medical Chief of Respiratory Medicine when he had his staff improperly code the files of his patient’s.
4. Refuse to participate in or conceal unethical practices or procedures.
4.1. Act in a professional and ethical manner at all times.
Neither the staff nor the Medical Chief acted in a professional or ethical manner when corners were cut on their clients.
4.3. Be knowledgeable about established policies and procedures for handling concerns about colleagues' unethical behavior. These include policies and procedures created by AHIMA, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations.
Again neither the staff nor the Medical Chief is aware of the AHIMA Code of Ethics because of the discrepancy in the files.
4.6. Participate in,...