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.
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.
Editor's note: This is part one of a series about medical identity theft. Look for part two in an upcoming issue of BOH.
Privacy and security officers are sitting on a hoard of valuable data: medical identity information. Social Security numbers. Medicare, Medicaid, and other insurer numbers. Credit card and bank account information. This data can fetch a high price on the black market, and medical identity theft costs patients, providers, and insurers millions of dollars a year. The lure of medical identity information makes healthcare organizations an appealing target for criminals, from large operations launching sophisticated hacking schemes to smaller groups running tried and true fraud scams.
A 2015 study conducted by the Ponemon Institute and sponsored by the Medical Identity Fraud Alliance (MIFA), the Fifth Annual Study on Medical Identity Theft, found that medical identity fraud nearly doubled between 2010 and 2014. More than 2.3 million adults were victims of medical identity theft and fraud in 2014 alone. The average cost per victim was $13,500 and the combined out-of-pocket cost was approximately $20 billion. But the financial impact is only the tip of the iceberg. Medical identity theft can result in physical harm to a patient if the medical record is altered to include another person's information such as allergies, disease status, or blood type.
Healthcare organizations often absorb some of the costs, and if the stolen PHI was used to commit Medicare or Medicaid fraud, they could be investigated by the OIG.
The stakes are high but by raising awareness and championing education and robust security programs, privacy and security officers can help their organizations stay one step ahead of criminals.
When compared to data from past surveys, HCPro's 2016 HIM director and manager salary survey revealed a harsh truth that many HIM professionals already know: There has been little movement in HIM manager and director salaries over the years.
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.
