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.
So what's it like from the HIM professor's point of view? We catch up with 37-year professor Anita Hazelwood, RHIA, FAHIMA, program director of HIM at the University of Louisiana at Lafayette.
This article is based on the results of MRB's quarterly benchmark survey. This month, we chose to survey respondents on EHR implementation and challenges.
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.
It's a brave new world out there for business associates (BA). BAs needed to comply with the HIPAA Security Rule and the use and disclosure provisions of the Privacy Rule in February 2010 as a result of the HITECH Act. However, the Office for Civil Rights (OCR) held off on any enforcement activities-that is, until recently.
The July 2013 MRB article I wrote discussed the importance of competency and skills testing in the workplace relative to new and evolving roles in the HIM department. In this issue, we discuss "not knowing what you don't know." In other words, there is a significant knowledge gap about the importance of EDMS in EHRs.
