Ruthann's CDI Blog
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Ruthann’s CDI Blog…..informal writings about clinical documentation in patient records…everything here is tested through my work and research on CDI….nothing here is “official”. I hope you will find it to be a useful, perhaps even supplemental tool for your work. And, on a really bad day, something to help uplift your spirits and gain some perspective! |
Some thoughts on CPOE and CDI
One of the Stage 1 requirements for Meaningful Use of the EHR is use of Computerized Patient Order Entry (CPOE). Specificallly, the regulations require: Enable a user to electronically record, store, retrieve, and manage, at a minimum, the following order minimum, the following order types: 1. Medications; 2. Laboratory; 3. Radiology/imaging; and 4. Provider referrals. Most CDI'ers probably had the same thought as me when reading this regulation.
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Are problem lists a problem?
Meaningful use proposed regulations state that the provider's EHR must enable a user to electronically record, modify, and retrieve a patient's problem list for longitudinal care (i.e., over multiple visits) in accordance with the applicable code set as required by law (i.e. ICD—9-CM, SNOMED). While it was easy to find the definition for technical requirements of the problem list in the MU criteria for the EHR, it was not as easy to find a definition for exactly what the problem list is. What's a LOINC?
I came across the acronym LOINC in the Meaningful Use Criteria in the Federal Register. In Stage 1, providers will be expected to submit structured laboratory data to public health agencies interfacing with LOINC. It turns out that LOINC is a coding system for laboratory tests. If members of the CDI team are represented on the EHR/MU committee, the term may get thrown around, so it might be helpful to have a general understanding of LOINC.
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Don't rush to make bad data available to the masses
The HIT Policy Committee is charged with making recommendations for use of the EHR in eight areas, one of them, number 5 in section 3002(b)(2)(B) of the PHSA, states: "The use of certified electronic health records to improve the quality of health care, [such as by promoting the coordination of health care and improving continuity of health care among health care providers, by reducing medical errors, by improving population health, by reducing health disparities, by reducing chronic disease], and by advancing research and education"
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A week of blogging about the EHR, MU, and QM
It's been a while since I have blogged on almost a daily basis (9 days to be exact). To those of you who are avid regular readers of the blog, my apologies. But I'm back now and because I have a week of blogging to make up for, I will be blogging twice a day for the next week about the relationship between CDI and the electronic health record (EHR), meaningful use (MU) criteria, and quality measures (QM). With movement on health care policy in the past week, Washington will no doubt be consumed with healthcare issues - and that includes the ARRA dollars going to hospitals to offset the costs of implementing an EHR. Along with those dollars come criteria that set minimum requirements for EHR capabilities. While this is viewed primarily as a technical (i.e. IT) task, technology is meaningless unless the content (the clinical documentation) is of high quality. So, I started below with some thoughts on the possibilities for integrating the review of the health record for quality measures with the CDI function. See what you think......
Are you reviewing documentation for quality measure compliance?
With the ever increasing number of CMS quality measures required for hospital payments, some healthcare systems may be taking steps to interface clinical documentation improvement with quality measures collections functions. There are a few approaches that may make sense, depending on your organization's structure and political environment. Does a verbal query become part of the patient's record?
As a result of yesterday's post about verbal query policies and procedures, the question has come up as to whether a verbal query becomes part of the patient's record. The simple answer to that question is that it depends on your organization's policies about queries in general. If your policy states that queries become a permanent part of the patient's record, then that policy should apply across the board. Initial weigh-in on verbal queries
Although it has only been a few days since the poll question asking about verbal query policies was posted, 88 percent of the voters say that their facility's policy allows querying, but also requires the reason for query to be documented. So, if we assume that these policies require that everytime a query is asked verbally, the reason for query as well as the query itself is recorded in the CDI program records then the compliance, fraud and abuse issues that have been concerning the regulatory bodies and others about verbal queries is a non-issue. Here's the key.....the documentation and enforcement of the policy. |
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