Improving Acute Care Documentation

Improving Acute Care Documentation PowerPoint PPT Presentation

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Quality Improvement Plan Improve Hospital Documentation. The ProblemInterventionsTimelineInternal Monitoring (Optional at This Time). Acute Care Documentation The Problem. No Valid Admit OrderUntimely or Incomplete History and PhysicalMissing Operative Reports and ConsentsUntimely Discharge Summaries.

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Improving Acute Care Documentation

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1. Improving Acute Care Documentation QSOURCE And Your Hospital

2. Quality Improvement Plan Improve Hospital Documentation The Problem Interventions Timeline Internal Monitoring (Optional at This Time)

3. Acute Care Documentation The Problem No Valid Admit Order Untimely or Incomplete History and Physical Missing Operative Reports and Consents Untimely Discharge Summaries

4. Conditions of Participation in Medicare and State Regulations 50-60% of H & P’s Lack Description of Medical, Family, Social and Surgical Histories and/or Review of Systems 20-30% Lack Signatures on Orders 50-60% Admit Orders Are Incomplete (Date, Time, Setting, Justification, Signature) 50% of Records Coded Without Discharge Summaries Have Incorrect Diagnoses

5. Causes Decreased LOS Ambiguity Business Liability Priority Physician Investment

6. Hospital Interventions Self-Audit and Monitoring Administrative Buy-In Physician Education and Investment (Hospital Does Not Get Paid) Regulatory Consequences Monitoring Use of Resources Paybacks, Fines, Penalties

7. Admission to Acute Care Date Time Diagnosis Comorbidity – Unique Medical Necessity Physician Signature Retroactive or Change Orders Also Need the Date and Time Services Start(ed)

8. Admission Orders Hard to Find Missing Date and Time No Setting or Diagnosis Unique Medical Necessity Over Half Would Fail (non-clinical review)

9. Discharge Summary Policy (Within 30 Days of Discharge) 40% of Records Coded and Billed Without the Discharge Summary Improved Discharge Summary Timeliness Improves Patient Follow-up Gold Standard is Complete Discharge Summary Before First Billing (even for stays less than 48 hours)

10. Physician/Clinician Role in Improving Acute Care Documentation Complete Admission Order Date, Time, Setting, Diagnosis, Other Complete History and Physical History and Review of Systems Complete Operation Reports and Consents Timely Discharge Summaries (before billing)

11. Physician Investment Good Patient Care Work Environment P4P Linked Payment to Come (hospital denial leads to physician denial) Knowing Who to Listen to (UR advocates)

12. Internal Monitoring Tool Complete Admission Order Complete and Timely History and Physical Complete Operative Reports and Consents Timely Discharge Summaries (within X days of discharge) X = 0 to 30 days

13. eTechnology Order Entry Systems Dictation Systems Electronic Records Hospital Physician Office

14. Reference List Timely History and Physical Admission Orders Conditions of Participation and Timely Submission of Records to the QIO Completion of Discharge Summaries Explanation of Technical Denials

15. Case Example List Timely Discharge Summaries Timely Admission Orders 11/22/06 3:15 AM Admit to acute care for CHF with HTN, DM, and CRI 2/5/07 4:30 PM Admit for colonoscopy in AM, GIB. Pt. has severe rheumatoid arthritis and cannot do prep on his own. 5/6/05 2:30 PM Change to inpatient as of 8:00 AM this morning. Pt. remains febrile and severely nauseated.

16. Conclusion Improved Documentation Better billing reimbursement for the hospital Better patient care and follow-up Physician Participation Physician Leadership Physician Champion Administrative Support

17. Questions and Discussion QSource Contact: Richard Bender 901.682.0381, ext. 2630

18. Thank You! QSource (the Tennessee QIO) and Your Hospital

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