If you are gearing up for a computerized provider order entry (CPOE) implementation, there are some tips and tricks that will help you stay on top of the transition.
Somewhere between the third urgent item on your to-do list, getting your budgets prepared, and responding to the latest auditor's requests lies the omnipresent responsibility of nurturing the validity of the medical record. HIM professionals have traditionally been the legal custodians of the record. (After all, who else is daring enough to testify in court on the accuracy of the EHR?) Have we also by default become the custodians of data integrity?
Hardware, software, people, policy, and process must work together to achieve your organization's EHR goals. One of the earliest matters that policy must address surrounds organizational readiness for an EHR. In fact, having a policy of regular readiness assessment is an important step toward success. Even if a certain project with a certain group goes smoothly, that doesn't guarantee success for another project. You may think a policy that focuses attention on planning is not necessary, but implementing an EHR is a spiral of change, with each cycle repeating itself in many ways, often with new twists and turns.
Editor's note: As part of our yearlong celebration of MRB's 25th year, we wanted to take a look back at article excerpts from years past. In some ways, things haven't changed much-getting physicians to complete documentation in a timely manner is still a challenge-but in others, it is clear that HIM has come a long way.
I promised in a previous “Standards of the month”column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.
After 10 years, the requirements for signatures on lab requisitions are still in flux; CMS published the latest change to the lab signature requirements in the 2011 Medicare Physician Fee Schedule (MPFS) final rule published in the Federal Register November 29, 2010.
As part of our yearlong celebration of MRB’s 25th birthday, this month we are featuring an interview with the newsletter’s founder, Jennifer Cofer Flanagan. Flanagan is also the founder of Opus Communications (now HCPro) and previously served as president of AHIMA (formerly the American Medical Record Association), as well as director of communications and professional practices for the organization. She is currently on the board of trustees for the North Shore Medical Center based in Salem, MA.
The last thing you need is more to do, but when it comes to preparing your HIM department for EHR go-live, an ounce of prevention is worth a pound of cure.
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.
