I have recently heard questions and discussion about the use of abbreviations within the medical record. With that in mind, this quarter's Joint Commission column will outline the requirements for abbreviations and provide guidance regarding the pros and cons of expanding the limited "do-not-use" list
Perhaps it's because I reside in Chicago?home of both Oprah Winfrey and the American Health Information Management Association?but lately I have been thinking about "aha moments" for HIM professionals.
CMS' fiscal year 2015 IPPS final rule focuses on quality initiatives mandated by the Affordable Care Act, including updates to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program. This quality focus creates a need for increased interdisciplinary collaboration across quality, HIM, risk management, revenue cycle, compliance, and technology.
Physicians have long treated patients knowing that some of the problems keeping them sick were problems that medicine couldn't fix--lack of food, electricity, or money to pay for medicine. These are the types of problems that often send patients back to the hospital after they are discharged home. Today, some physicians can write a prescription to solve these problems the same way they order medicine.
Many hospitals have been adding group rounds as a means of improving communication and care for patients. These rounds give case managers (CM) an opportunity to better understand the patient's condition, learn about any potential factors that might extend LOS, and prepare for any potential barriers that might lead to readmission after discharge.
