The move to an electronic record affects all areas of the hospital, and the release of information (ROI) function is no exception. In our first quarterly benchmarking survey of 2011, MRB examined the ROI practices of hospitals with hybrid or fully electronic records.
Chart completion, in the traditional sense, typically entails someone reviewing a record to ensure that all components are complete and signed in accordance with organizational policy. Over the years, organizations have revised their policies to meet Joint Commission standards and other directives.
I was recently working on an EHR project, and there was a deep and vibrant discussion about which functionalities are part of the “core” EHR and which are “add-ons.” I came to the conclusion that the line is becoming quite blurred between what has historically been hospital information system (HIS) vs. EHR functionality.
The frequency of CMS surveys seems to be on the rise. With that in mind, I thought I would address three of the top medical record concerns that might plague you if CMS comes knocking on your HIM department’s door. We have covered these in past columns, but it never hurts to take another look at the big three: verbal orders, history and physical reports (H&P), and post-anesthesia evaluation.
HIPAA privacy officers don’t have eyes in the back of their heads. Nor can they be everywhere at once. But they can increase their ability to monitor compliance by sharing the responsibility with other staff members.
Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.