Abstract

In KK Women's and Children's Hospital (KKH), clinical case notes audits are conducted quarterly for compliance of approved acronym usage. Existing process involves the retrieval of mixed hardcopy and electronic case notes for referencing manually to the list of approved abbreviations by clinical coder. Through the use of process re-engineering and excel application, audit coverage can thus be expanded with reduction in human dependency and errors with significant resultant savings in time spent.

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