Legible.Complete.Dated, timed, signed, and authenticated.That's what section 482.24 of the Medicare Conditions of Participation requires of your medical records.
If you are gearing up for a computerized provider order entry (CPOE) implementation, there are some tips and tricks that will help you stay on top of the transition.
Editor's note: As part of our yearlong celebration of MRB's 25th year, we wanted to take a look back at article excerpts from years past. In some ways, things haven't changed much-getting physicians to complete documentation in a timely manner is still a challenge-but in others, it is clear that HIM has come a long way.
Hardware, software, people, policy, and process must work together to achieve your organization's EHR goals. One of the earliest matters that policy must address surrounds organizational readiness for an EHR. In fact, having a policy of regular readiness assessment is an important step toward success. Even if a certain project with a certain group goes smoothly, that doesn't guarantee success for another project. You may think a policy that focuses attention on planning is not necessary, but implementing an EHR is a spiral of change, with each cycle repeating itself in many ways, often with new twists and turns.
Somewhere between the third urgent item on your to-do list, getting your budgets prepared, and responding to the latest auditor's requests lies the omnipresent responsibility of nurturing the validity of the medical record. HIM professionals have traditionally been the legal custodians of the record. (After all, who else is daring enough to testify in court on the accuracy of the EHR?) Have we also by default become the custodians of data integrity?
It will take time for coders to become comfortable translating terminology used in physician documentation to root operation terminology used in ICD-10-PCS, according to Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, who spoke during HCPro’s November 18, 2010, audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.” But Jones thinks coders will get there eventually.
In 2010, HCPro’s Revenue Cycle Institute conducted its second annual in-depth study on RAC preparedness among healthcare providers. The results are now in: RAC audits have picked up, but preparation and education are still under way for many, and HIM plays an important role.
