Explain the problems that these deficiencies may cause a health care organizatio

Question

Explain the problems that these deficiencies may cause a health care organization. CASE Documentation Improvemen Laura just finished a documentation audit. She was not surprised to learn that documentation problems. The top 3 problems identified were the following: History and physicals (H&Ps) do not meet Joint Commission and medical staff regulations for time of there were significant completion and content Discharge summaries do not meet Joint Commission and medical staff regulations for completion and content . Progress notes are very brief and do not adequately describe the patient's improvement or lack thereof. 1. What should Laura recommend to the HIM director to improve documentation? 2. Who should be involved in this documentation improvement program? 3. What else would you want to know? 4. What type of follow-up should be performed? When?

Explanation / Answer

1,medical records is a document important for clinical,para-clinical and financial information about the patient..some facilities seeking an RN or coding professional to fill the CDS(clinical documentation speciality) role with RNs, some coding trading must be followed..

Coders must have good communication skills and basic knowledge of anatomy,oncology and pathology and a good disposition keep involve everyone in CDIP( clinical documentation improvement program)

HIM director worker with the patient care administrator of each CDIP covered service line and routinely provides feedback about how each service line is contributing to the program.A new software package helpful to operating surgical theatre procedure documents rather than hand writing..detailed presentation is important to avoid malpractice allegations..The process of computerized medical information must be improved for quality and accuracy of the coding process..proper training and instructions given to all health professionals to document the patient data in timely and clear presentation with eligible handwriting.. avoid sticky notes..

2, Deputy director, health information manager,coding staff,surgical management and physician involved in the documentation improvement program..

3, medical record documents is to be timely, meaningful, authenticated,and legible..All relevant documents and entries content should be entered in to the medical record at the time the services is rendered..EMR must be used for documentation in all areas..

4, Follow up is documented for patients who need periodic visits.. Return to office (RTO) is a specified amount of time is required at the time of visit or as follow-up to consultation,laboratory,or other diagnostic reports must be recorded as appropriate..

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