Regardless of the safeguards in place in any electronic document management system (EDMS), sometimes a document ends up in the wrong patient’s record. It was a reality in the paper world, and it is a reality in the scanned record world. Obviously, it was easier to rectify in the paper environment. So how does one address this issue with a hybrid electronic record?
When it comes to release of information (ROI), it may seem that exceptions are the rule. But you must know when you can and cannot release information to protect the privacy of your facility’s patients.
As physicians, we are quite aware of the severity of illness of the cancer patients we treat. However, we frequently are not cognizant of the elements of their diseases that need documentation or clarification in the medical record to accurately portray the complexity of those patients. I’d like to discuss some of the issues that surgeons, oncologists, family physicians, and pediatricians might face that need some attention in documentation.
The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor is it a simple matter of training coders and implementing a revised encoding system. This will probably be one of the biggest transitions hospitals and HIM directors and coders have seen in many years.
Medically unnecessary services and incorrectly coded items had the highest amounts of RAC overpayments collected in the demonstration project, according to CMS.
Those of us who work in clinical settings are familiar with situations involving medical ethics when it comes to patient care. End-of-life decisions, resource utilization vs. quality of outcomes, genetic testing, pro-life issues, and other hot topics create endless ethical and moral discussions. And don’t forget to mix in a little government healthcare policy and discussion on rationing of healthcare and on whether healthcare is a right or a privilege.
EHR implementation is a “big, hairy animal,” according to Meg McElroy,RHIA, MBA, HIM and medical staff services director at Children’s Hospital of Milwaukee. McElroy has been working toward having a fully electronic record for years. “It’s so expensive, and how do you just get it done?” she says.
