A lot can go wrong when an elderly patient is discharged home, from medication errors to transportation problems or self-care comprehension issues. However, an organization can create a solid discharge and transition process by focusing on some simple elements.
In October 2014 a record number of hospitals were fined for excessive care transitions. In total, CMS penalized some 2,610 hospitals, and will assess fines between October 2014 and September of this year. Through these penalties, the government has given hospitals sufficient incentive to revamp their processes with an eye on preventing readmissions and improving transitions.
RC.01.01.01, Content of the Medical Record, did not top the list of survey findings for hospitals in the first half of 2014, according to the September 2014 issue of Joint Commission Perspectives. Nor was it on the list for critical access hospitals at all! However, 49% of hospitals surveyed received a requirement for improvement for this standard, primarily in the EPs related to timing and dating entries. This indicates hospitals are still using a lot of paper records. That said, the downward swing is encouraging as more and more hospitals fully implement the EMR.
Q: My facility no longer registers patients under aliases, but will allow them to opt out of the patient directory. However, opting out of the registry will not exclude our patients from the operating room (OR) list. At one time, the facility's CEO received the daily OR list with full patient names so he could visit board members, donors, or others whom he knows at our facility. HIM changed this practice so that patients' names would not be on the OR schedule provided to the CEO. The CEO took this matter to the hospital attorney, who said the names could be included because the use of PHI by the CEO to determine whether and when a patient visit is appropriate is permitted by HIPAA as it is part of healthcare operations. Is it a violation of HIPAA for the CEO to use PHI to track patients in this manner?
Coronary artery bypass graft (CABG) procedures are not the only ones coders will report using the root operation bypass in ICD-10-PCS. Surgeons can create bypasses in other vessels of the body.
Inpatient coding professionals are used to DRG systems where all of the diagnoses and procedures map to a single DRG. So they may not look for additional procedures and services to report outside of that DRG.
