The Analysis of the Causes of Hospitalized Patients’ Medical Records Deductions

Background and Objectives: Hospital deductions are one of the main concerns of hospital managers in cost management and also one of the most controversial issues between insurance companies and hospitals. The objective of the present study was to analyze the major causes of hospital inpatient medical records deductions.

Material and Methods: This study was a mixed-method research that was done in four-step in 2017. In the first step, systematic review of the main causes of deductions in hospital inpatient medical records was done. In the second and three steps, a questionnaire was designed from the results of the first step to interview the experts in this field. In the final step, after summarizing the results of the three steps, the final causes of hospital inpatient medical records deductions were determined using Delphi technique.

Results: Additional requests for encoding in surgical procedures by surgeons and anesthesiologists, sending documents with the signature of the surgeon assistant without his presence in operation, lack of interaction with insurance and its follow-up and a tendency to reform of deductions, employing people with the unrelated specialties in the relevant unit, lack of continuing and comprehensive training for staff, additional request at drugs and supplies fees, incomplete documentation, lack of documentation for full-time physicians and differences in the implementation of guidelines by the insurers were the most important causes of inpatient medical records deductions

Conclusion: Given that human error is one of the main reasons for inpatient medical records deductions, justifying physicians and training staff for completing medical records on the principles of proper documentation and quality of data recording and ensuring uniformity of policies and enforcement of insurance guidelines seem essential.