Having recently returned from teaching the HCPro Accreditation Specialist Boot Camp, I was reminded that our medical staffs continue to have challenges with documentation requirements that have existed at least as long as most of us have been HIM professionals. I thought it was a good time to remind HIM professionals and their medical staff of 12 documentation requirements that are still a major focus during Joint Commission surveys, and persist in being a record completion challenge.
CMS released its proposed rule for stage 3 of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs (https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-0668...) in March. The intention is to simplify the EHR Incentive Programs, drive interoperability, and allow providers to further focus on patient care. The rule proposed a transition to a single meaningful use stage, with stage 3 being the final stage in the program. It would incorporate portions of stages 1 and 2.
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.
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.
Compliance with the 2-midnight rule has been tricky for many organizations?and things aren't expected to get easier anytime soon. The 2016 OPPS proposed rule may bring some additional tweaks to the 2-midnight rule (see related story, "Proposed OPPS rule suggests tweaksto 2-midnight rule," in the September issue of CMM), and education and enforcement may change hands from Recovery Auditors to Quality Improvement Organizations.
