The healthcare industry is changing rapidly, and if you've been paying attention to the news you've probably noticed the recent wave of hospital mergers.
In the August and September issues, CMM told you about a recent set of revisions to the discharge planning section of the CMS State Operations Manual. While most of the changes amounted to housekeeping, CMS did take the unusual step of including some non-binding best practice recommendations related to discharge practices. Surveyors won't penalize your organization if you don't follow these recommendations, but experts recommend following the agency's advice whenever possible.
Doctors might know what's best for their patients, but patients don't always choose to follow that advice. Over these past few issues, CMM has talked about CMS' new suggested best practices, which were included in revisions to the discharge planning section of the CMS State Operations Manual. These new recommendations call on facilities to carefully investigate patients' refusals to heed medical advice and document their reasons for doing so. However, there is more you can do when a patient balks at a physician's instructions, says Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, senior director of case management at West Region Kindred Healthcare, Hospital Division.
Imagine a hospital as a sentient being that holds within it all things necessary to heal you from illness or injury. The HIM department, or medical records department, is this being's memory. Without it, there would be no continuum of patient care. Sometimes, it's the hospital's memory that serves to produce an otherwise overlooked diagnosis.
