Today's nurses have more demands on them than ever, with high patient loads and an increasing number of tasks to complete. Often, this increases the likelihood that certain aspects of care may be missed?whether it's needed education on insulin injections that weren't provided before discharge or a patient who develops a pressure ulcer because he or she wasn't turned often enough.
Q: The company I work for has long debated what to do about medical records that are sent out on CDs. We concluded that since paper records could not be encrypted, we shouldn't have to worry about encrypting the CDs.
I was recently discussing the state of EHRs in regard to the poor quality of the documentation with a colleague who has been a practicing HIM professional for more than 35 years and currently works for a large group of hospitals as the coding director.
When a patient suffers a traumatic injury or poisoning, we need to report how they became injured and where they were when it happened. You already know this from ICD-9-CM.
