Legible.Complete.Dated, timed, signed, and authenticated.That's what section 482.24 of the Medicare Conditions of Participation requires of your medical records.
Facilities that hold regular interdisciplinary care coordination rounds often say such meetings save time. However, the rounds can turn from time-savers to time-wasters if the matters discussed do not stay on topic or drag on.
Case managers and social workers have an active role in helping patients and families make end-of-life decisions such as using palliative care and hospice.
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.
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.
