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.
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 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.
In what was perhaps an effort to remind providers to consider medical record retention as they move to EHRs, CMS released MLN Matters SE1022, which addresses medical record retention limits and media formats.
With the end of the year approaching, you, along with many of your HIM director and manager colleagues, may soon be tasked with conducting annual staff evaluations. Chances are it isn’t your favorite task of the year. But it needs to be done.
