Medical Records – The Defense “Mitigating Liability” July 11, 2013.

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Presentation transcript:

Medical Records – The Defense “Mitigating Liability” July 11, 2013

Quality Auditing Process Flowchart Risk Assessment Tool – Incident & Wounds

Change of Condition COC SBAR Form SBAR Flow Charts

Pressure Ulcer Monitor

Admit Audit & Instructions

Behavior Drugs Antipsychotics Monitor & Instructions Non-Antipsychotic Audit & Instructions

ID Team Care Conf Record Fall Risk Pressure Ulcer Risk Aspirin Risk Bleeding Risk

Bed-Hold Discharge Audit

Diabetic Monitor

Anticoagulant Audit

Audit Calendar Adm Oversight

Audit vs. Tabulation From QAA to QAPI

Updated ADMIN P&Ps (Notice of Privacy Practices) (Business Associates) (Elder / Dependent Adult Abuse) (Informed Consent / Psychotherapeutic Med (Antipsychotic) and Restraint Devices) (Physician Extenders Physician Assistants Nurse Practitioners) 0 A014 (Medication Documentation - KNS)

Updated HIM P&Ps (Health Information Record Retention Guidelines) (Notice of Privacy Practices) ( Monitors - Completion Instructions) (Admission Day Combined Monitor) (Behavior Psychotherapeutic Drugs Antipsychotic) (Behavior Psychotherapeutic Drugs Non- Antipsychotic) (Behavior Psychotherapeutic Drugs Non- Antipsychotic - INSTRUCTIONS)

Updated HIM P&Ps (Medicare Log) (Medicare Certification - Recertification) (Surveyor Electronic Health Record Protocol) 0 A014 Medication Documentation – KNS 0 B001 CareTracker Training Contract

Highlights on HIPAA

Texting

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