RC.01.01.01, Content of the Medical Record, did not top the list of the 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.
MRB asked HIM and release of information (ROI) professionals about their ROI practices for its first quarterly benchmarking survey of 2015. (The survey was completed in October 2014.) Half of survey respondents are HIM directors or managers (52%). Other respondents identified themselves as non-managerial HIM staff members (18%) or ROI directors or managers (4%). The majority of respondents (65%) work in hospitals.
Preventing readmissions is a hot topic these days. CMS has imposed new financial penalties for organizations that don't successfully prevent 30-day readmissions for patients with certain medical conditions, and organizations are always looking for new strategies to ensure patients are successfully able to move to the next level of care.
Case managers rejoice. CMS recently sounded what is being called the death knell of the 2-midnight rule certification in a final rule published in the November 10, 2014, Federal Register.
In September 2014, CMS and the Office for the National Coordinator (ONC) released a final rule that offers enhanced flexibility for eligible professionals, eligible hospitals, and critical access hospitals using certified EHR technology (CEHRT) and working toward meaningful use attestation (https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-21021.pdf). The final rule regulations became effective October 1, 2014.
Do observation patients belong in their own unit? The answer is debated at many organizations. Some say establishing a separate unit brings numerous advantages, from improved ED throughput to shorter lengths of stay. Others say some facilities may not need one.
