Patient care continues to move from the inpatient setting to outpatient. With this change, the challenge of securing comprehensive documentation that articulates the services rendered and the patient care provided now needs to extend across the care continuum.
Q: Our state child support enforcement agency requested the medical records of one of our pediatric patients. Are we allowed to respond to this request without a subpoena?
RC.01.01.01 is one standard that just won’t go away. The first half of 2017 (January–June) standards compliance data was published in the September issue of The Joint Commission’s Perspectives, and RC.01.01.01 made the list again. This means that the standard has been on the top 10 list for at least the last five years, along with other frequent flyers such as Environment of Care, Life Safety, and Infection Prevention.
My experience in ICD-10-CM documentation and coding integrity is that many physicians know in their heads what is wrong with their patients; however, they have not been taught to “think with ink” in describing their patients' illness in the EHR using ICD-10-CM’s language to ensure proper coding.
