Delinquent Medical Records

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

In order for a hospital to be eligible for reimbursement through Medicare, they have to show that they are compliant by way of the Conditions of Participation. One way to show this is by getting an accreditation through The Joint Commission who meets the Medicare Condition of Participation standards. (La Tour, 2013).

In the event of releasing any patient information it is important to make sure that all of your T’s are crossed and your I’s are dotted before the transaction is complete. However, because specialized patient records, such as Mental health or substance abuse cases, contain not only strictly medical information, but also therapeutic mental and emotional information, the release of this type of information could cause some damage to the patient (McWay, 2010, p. 227). This is why the release of information concerning this type of patient records is different from that of a patient record without delicate information in it.

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,

We’ve all heard the saying, “If it’s not documented, it didn’t happen.” While it is an age old saying, it reveals one of the biggest issues within healthcare. The issue is not just proper and accurate documentation, but having a documentation that can keep up with the rapidly shifting and changing landscape that is healthcare. “Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing.” (Recognizing the Value of Clinical Documentation Improvement, 2014).

CMS uses three years of discharge level data of hospital to determine the expected readmission rate. Based on the hospital’s performance, if the predicted readmission rate for next year is higher than CMS-expected rate, the hospital incurs a penalty up to 3 percent. (refer to attachment 2,3 for penalty calculation and payment adjustment). Central Health’s performance has been declining since last three years, predicting higher readmission rate than the national average. For FY 2017-18, Central

Quality can be difficult to measure, which is what has halted the strong pursuit of quality in the past. Healthcare organizations use quality assessment to measure quality against some established standard. This includes “defining how quality is to be determined, identification of specified variables... and the collection of appropriate data to make the measurement possible (Shi, 2015, pg. 493). The Affordable Care Act set new standards and incentives for achieving quality of care. This includes offering Medicare reimbursements for hospitals with low readmission rates, and ensuring that (not-for-profit) hospitals complete a community health needs assessment (to ensure that the needs of the community are being met) and by implementing HCAHPS scores, which measures efficiency and efficacy of care using patient surveys. HCAHPS and hospital readmission good example of how quality of care can be measured in efficiency as well as

To deal with this information gap, the Hospital Quality Alliance program integrated the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey into its series of measurements. Several hospitals have committed to providing responses to the survey from patients that have been discharged from their hospitals. The Centers for Medicare and Medicaid Services (CMS)

As enforcement activities increase by the Department of Justice, though the above report of fraud and abuse was intentionally carried out over a seven-year period, it becomes clearer every day that even an unintentional billing mistake can lead to charges of fraudulent billing with severe penalties. In the end, the risks of not having an update to date and strong compliance program can potentially result in the damage financially to the specialty physicians practice and reputation can be substantial. It also requires

As you well mention the Joint Commission not only evaluates the services of the hospitals but also the ones of other centers that offer the care of the patient, whether ambulatory care, home care and mental health institutions. This is good because when the patient is referred to one of these services we can have a piece of mind because if they are accredited we know that the service they provide are of quality. According to Hebda & Czar “the Joint Commission introduced new emergency management standards for hospitals, long-term care facilities, and behavioral health and ambulatory care that focus on the concept of community involvement in the management process” 2013, p.449. The goals of the commission are directed to watch for the care

Further statistics have revealed around 20 percent of Medicare recipients released from hospitals were rehospitalized within thirty days and that 34 percent were readmitted within ninety days of being discharged ( Jencks, Williams, & Coleman, 2009). Additionally, Medicare will now penalize hospitals for patients who were readmitted within 30 days (Stone & Hoffman, 2010). Jenny Minott from Academy Health (2008) asserts “The transition from the inpatient to the outpatient setting is a critical point along the care continuum in which there is a real opportunity to prevent readmissions” (p. 5). Many believe that some hospital readmissions are avoidable and could be thwarted with fairly uncomplicated methods (Alper, O’Malley, & Greenwald, 2016; Anthony, Chetty, Kartha, McKenna, DePaoli, & Jack, 2005; Jacks, et al., 2009; Minott, 2008; Stone & Hoffman, 2010). Therefore, reducing hospital readmissions has been the center point of attention among hospitals, but the challenge has been identifying those components that are directly responsible for, including the quality of care during the hospitalization and the discharge planning (CDC, 2016). Wherefore, an area that needs considerable attention is the hospital discharge

Accurate and comprehensible medical records documents are crucial for a positive outcome for the patient and health care providers. Health records sequentially convey significant details concerning patient’s health history and future care plans. These records are pertinent when initiating care in the acute and chronic setting for the patient. Medicare, Medicaid, and other personal health care providers necessitate rational documentation to guarantee that a procedure and/or examination is consistent with the individual’s health care coverage. The documentation also authorizes the place of health care treatment, eligible medical requirement and suitability of diagnosis and/or therapy, and that the services rendered were appropriately documented. Precise and reliable medical documentation should be recorded at the time of treatment or shortly after the intervention. Inappropriate documentation can result in erroneous and inappropriate imbursement for provided health care services.

Case management in the emergency department, constantly works to find the right data in a patient’s record to ensure that they have the correct insurance coverage and can be admitted or discharged at the appropriate time and place. Even when the smallest amount of essential information is not documented, this otherwise straight forward process turns into a scavenger hunt for who has seen the patient, interventions that were done and for what reasons, and at what time all of these things took place. ED case manager Veronica Kountz (personal communication, March 20, 2015) states that the inadequacy of documentation can lead to insurance companies not covering patient costs, which the hospital then has to absorb. Before a patient can be admitted or discharged, the right