Susan's Chart Auditing

" Dean helps his co-workers when available and seeks assitance when needed" " He precepts frequently and always willing to help teach the nursing students when ever he can" " Dean interact well with patients and families" "He is repectful of patients and family members and will ask them if they have any questions or concerns" " Dean exhibits critical thinking and attention to detail in order to prevent any patient from harm" Dean is a mentor to both students and new RN's in the ER." " Dean is caring and empathetic and sits with his patients to provide active listening and comfort" " Dean is a good team member, always helpful" "Always will to take LPN students, RN students and high school students to help them

1. As the clinic nurse, what routine information would you want to obtain from S.R.?

She created a flow sheet used by the nurses to import data useful for review at

HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.

A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began

The fifth member of the team is the medical records manager. She has a bachelors in healthcare management. Her expertise with HIPAA rules and regulations is crucial. It is her job to evaluate security of the new systems to ensure that patient confidentiality is not breached. She will have input form other healthcare managers as well as others in the medical records department.

Monitoring everything, payroll, billing, human resource, scheduling, follow-up with nurses and employees, doctor requests, communicate with the doctor about patients and pre-authorization documents needed for the plan of care, HMO, training, physical therapy for patients.

Follows efficient, logical sequence; balances screening/diagnostic steps for problem; informs patient; sensitive to patient’s comfort, modesty.

Under the scope of practice of an RN from the New York State Education Department, an RN can diagnose and treat human responses to actual or potential health problems. To be able to perform those tasks a care plan must be made for each client. An RN manages the health care services such as observing and assessing the health status of clients and implementing/assessing nursing care. This all falls under the initial assessment of a client, which is within the scope of an RN. An RN uses information gathered as part of client assessment, they then have the capacity to assign client care to other members of the nursing team, RNs and LPNs, and assign tasks to other care providers such as nurse’s assistant. Even though there are parts of the nursing process that may be delegated to qualified personnel, the initial assessment is the RNs responsibility. The initial assessment is the basis for safe and appropriate client care, which makes it so vital and why not just anyone can perform it. RNs hold the overall responsibility in the nursing

1. Nurse-sensitive performance reviews and quality indicators are vitally important to maintain the health of the nation and the nursing profession in general. Some of the processes used to implement these include monitoring the supply of nursing staff, assessing the skill of such staff, and considering the education or certification of staff. Assessment, intervention, and RN job satisfaction are process indicators that are also important in terms of determining the quality of nursing care at a health facility (ANA, 2012).

Her responsibility as a medical necessity coder is to approve physician orders. When physicians order tests for their patients, Ms. Williams has to verify that CMS will pay for the specific test. In the event the order is rejected, she will contact the physicians. This could be the most difficult part of the job for her. Before she contacts the physicians, several steps would have to be taken. CMS requires a very high level of specificity when submitting orders. The majority of the time when providers are filling out order forms, they are not abiding by the strict guidelines CMS has. It is her job to help the providers reach the level of specificity with out disclosing exactly what CMS wants. This can frustrate the providers when there is a copious amount of hither and thither to get an approval. Providers are vocal about their annoyance and they feel like this is getting in the way of caring for the patients. Observing her in her element, I can conclude that she loves what she does and that she thrives under pressure. Witnessing the medical necessity coding process was a wonderful start to my day; the last area I will be in is Vital Stats, Death Certificates after my

As a PSC Jheanelle main functions are checking in patient, updating demographic information, obtain referrals, printing medication list, and putting together new patient paper work, collect co-payment complete the end of day deposit. Jheanelle also post charges daily, work the ClientTell cancelation, NOS report and the waitlist, work the bump list and scan medical records for the OPAT department. On occasions Jheanelle work the message box for Travel Well when there is a staffing issue. Jheanelle also work with the social workers and communicate with them regularly to announce patients needing help. Jheanelle also work with the nurses and providers when there is a late patient, walk-in and other patient

After meeting with her Senior Director and determining it was expected for her unit to improve their HCAPS scores, Dawn investigated what the current scored of her unit were. After looking up the unit’s HCAPS scores, she discovered the September of 2014 scores, in the categories of responsiveness of staff, and communications with nurses, were well below the average of like hospitals. She then started the managerial function of organizing by developing a plan to carry out the work needed to raise the unit’s HCAPS scores in these two areas.

Being compassionate and available to provide support to the patients and their families in difficult times

I was extremely excited to do this chart audit since I am conducting my DNP project on this topic. In my first audit last year our clinic had only 45% compliance with the guidelines and we were still following JNC 6 Guideline. However, after starting the project, the compliance has increased to 80% and care has been improved. This audit had brought in numbers that I could discuss with him in a professional way and it reflects a vast difference in quality improvement. Initially, chart auditing did not seem very appealing to the doctor but now it has become a norm for our clinic to do chart audit periodically. We still have to work hard in the area of patient compliance to the medications to prevent hypertension