Q: I am a certified case manager working in an acute care hospital. As part of our job requirements, when working in the emergency room (ER), we are asked to problem solve throughout the day. We often get requests for information on patients seen in the ER who have since been discharged.
Discharge planning has long been a challenge for organizations, but proposed revisions to Medicare'sConditions of Participation announced in November 2015 may make the process even more difficult.
Discharge planning has become more important in recent years. Not only is the government putting new focus on ensuring hospitals are helping patients to move to the next level of care more efficiently, but research shows that patients are safer and less likely to return to the hospital if these transitions are well managed.
This column is devoted to restraint and seclusion documentation; it provides support for, and a tool for, 100% review of patients in restraints and/or seclusion.
The Joint Commission and CMS have a common goal of reducing the use of restraints and seclusion in hospitals. Hospitals have come a long way in meeting this goal, and requirements for improvement (RFI) usually are received because of poor documentation in the medical record. Generally, recommendations result from lack of physician orders, physicians not seeing patients on-site, incomplete orders as to the reason for restraints and/or seclusion, and care plans not including the goal to remove patients from restraints and/or seclusion.
Often during surveys, there will be no patients in restraints or seclusion and the surveyors will ask for closed records to review. Once the medical record is closed, little can be done to correct documentation. Therefore, a solid open record review is essential to avoid recommendations.
A process for reviews
Review of open records of patients in restraints and/or seclusion can be performed in several ways. Of utmost importance is the development of a method to identify patients in restraints and seclusion on a daily basis, and to review new and recurring patients until they are discharged. For example:
1.Nurses, clinical documentation specialists, and tracer teams (plus others?) can review medical records each day to ensure documentation compliance
2.If the hospital has an EMR, HIM staff can review open records online to identify discrepancies in documentation and report back to each unit
3.HIM and IT staff can collaborate to develop a method of importing information directly from the EMR to identify documentation errors
Any of these methods should eliminate errors as long as they are corrected as soon as possible before patients are discharged.
Q: Is it permissible to take pictures of patients for identification purposes as a part of the registration process? Do the patients need to sign a consent form before their picture can be taken?
A: It is permissible to take pictures of patients for identification purposes if the patient agrees to it. Since the Privacy Rule considers full-face photographs to be a patient identifier, it is a good practice to get the patient's written consent to take a photograph and file it with the patient's electronic record. The patient should be allowed to opt out of the photograph if he or she chooses.
Editor's note
Brandt is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Opinions expressed are those of the author and do not represent HCPro or ACDIS. Email your HIPAA questions to Associate Editor Nicole Votta at nvotta@hcpro.com.
