As increasingly more healthcare providers transition to electronic health records (EHR), the need for secure conversion of paper charts to electronic patient documentation also increases.
As an HIM professional, you have long managed the quality and integrity of the health record. You know all components inside and out, aid in the design of forms to accurately and completely capture the necessary information, and point out potential data discrepancies in the record prior to finalization.
With the compliance date for ICD-10-CM/PCS implementation finally set in stone, all that's left to do is plan, plan, and execute plans. To help you, we asked Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, COBGC, CPCD, CCS-P, CDIP, senior manager at Blue and Company in Indianapolis, an industry expert on ICD-10, for preparation tips and action steps for ICD-10 implementation.
You're reviewing a case file and discover that a patient's recent readmission is due to a medication prescribing error made by a physician. Do you report it?
