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1
“HIM Workshop” Presented by:
Rhonda Anderson, RHIA
2
Today’s Topics
• Discharge Monitoring
• Audits / Monitoring – Admission – Certification and
Recertification – Physician Orders – Change of
Condition – MAR/TAR
– PPS Charting • Medicare
Certifications / Triple Check
• Physician’s Orders scanning
• Daily Charting • Diagnosis Coding • Face sheets
3
Teamwork
• You are a very important and critical part of the quality assurance team at your facility.
4
Completing a Puzzle
• Without all the pieces you would not be able to complete a puzzle
• Your audits ensure that all the pieces are there to ensure the quality and completeness of the medical record
5
Let’s Get Started
• Discharge Monitoring Process – Non-negotiable audit “MUST” be
completed for all discharges – Must be completed upon discharge from
Medicare Services and at final discharge
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Discharge From Medicare Services only
• Complete the right side of the audit form
• Once completed the audit form can be filed as follows: – In a binder in alphabetical order (the
audit will be retrieved at the time of final discharge for completion)
– At the front of the overflow file (recommended) the audit will be completed at final discharge
7
Discharged from Medicare and Facility
If the resident is discharged from Medicare and the facility at the same
time • Some items may be duplicate on the
audit form, complete each item only once
• File the audit form with the record until all applicable items are completed
• File completed monitor in the discharge monitor binder and retain for 1 year
8
Final Discharge
If the resident is being discharge from the facility but was discharged from
Medicare Services before • Complete the left side of the audit
form • Complete ALL items • File the audit form with the record
until all applicable items are completed
• File completed monitor in the discharge monitor binder and retain for 1 year
9
3520 Discharge Chart Monitor
• Central Region
• Midwest Region (same as Pacific)
• Pacific Region (same as Midwest)
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3520 Discharge Chart Brief Instructions & Policies
• Central Brief Instructions• Midwest Brief
Instructions (same as Pacific)• Pacific
Brief Instructions (same as Midwest)
• Central Policy• Midwest Policy (same as Pacific)• Pacific Policy (same as Midwest)
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Audits
• Admission – Non-negotiable audit “MUST” be
completed for all admissions
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Admission Monitors & Policies
• Central Region Monitor• Midwest Region Monitor• Pacific Region Monitor
• Central Region Policy• Midwest Region Policy• Pacific Region Policy
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Medicare Certifications
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• Certification is required upon admission
• 1st re-certification is due before the 14th day – (physician signature / date determines
the due date for subsequent re-certifications)
– Re-certifications are due every 30 days thereafter
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Content of Certifications
• Must state the following: Reason for continued inpatient / skilled careEstimate of time for continued inpatient / skilled care Discharge plan Physician Signature / Date of signature
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Delayed Certifications
• If Certification / Re-Certification is not completed timely, a “Delayed Certification” must be obtained from the physician and the delay must be explained
17
PPS Charting
• Daily documentation is required • Supporting documentation should be
consistent and reflective of MDS responses
• Standard of practice requires documentation of care and services delivered and resident’s response to care and services provided
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Triple Check
The purpose of this monthly meeting is to ensure complete documentation required to expedite payment for all
covered supplies and services
Daily audits for documentation of services, timely completion of
certifications and physician orders signatures are a critical part of this
process
19
Role of HIM in Triple
• Certification / Re-Certification reporting
• Scanning of signed physician’s orders
• Reporting PPS Charting trends
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Physicians’ Orders
What makes up a complete physician’s order?
• Drug name / dosage • Route • Frequency • Diagnosis for use • Behavior manifestation • Verification of informed consent
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Lunch
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Change of condition
– Non-negotiable audit “MUST” be completed daily
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• Where to look:– Physician’s orders – Nurses’ notes
• Description of incident• Notification of physician / responsible party /
resident • Charting every shift for 72 hours Nurses’
notes – New Care Plan or update to existing care
plan
Discuss findings and trends during stand up/ morning meetings
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Examples
What are some examples of a change of condition?
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Change of Condition Monitor & Policy
• Monitor (same for all Regions)
• Policy (same for all Regions)
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Let’s review the audit form and identify where
each item is located within the medical
record…….
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What would you change?
• Identify one step that would make your COC audit more qualitative?
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MAR / TAR
• Must be monitored daily
• PRN Medications must have the following documentation:– Reason for administration – Effectiveness of medication
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PPS Charting
• Medical record must have daily documentation of skilled services
• Documentation must be monitored daily to ensure timely corrections as needed including late entries
30
Diagnosis Coding
• Admission Diagnosis Form and Flow Sheet
• Presented by: Belen Dizon
31
Resolving Diagnosis
• Resolving Diagnosis process / flow sheet
• Presented by: Belen Dizon
32
Face Sheets
Printing Face Sheets
Admission & Discharge
Presented by: Belen Dizon
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Let’s share BEST PRACTICES
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Take Action
• Let’s develop one action plan for each of the topics discussed today
• Take these action plans back with you and implement when you return to your facility.
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Questions for discussion
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Thanks for Attending