“HIM Workshop” Presented by: Rhonda Anderson, RHIA 1

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 2

Teamwork You are a very important and critical part of the quality assurance team at your facility. 3

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 4

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 5

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 6

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 7

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 8

3520 Discharge Chart Monitor Central Region Midwest Region (same as Pacific) Pacific Region (same as Midwest) 9

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) 10

Audits Admission –Non-negotiable audit “MUST” be completed for all admissions 11

Admission Monitors & Policies Central Region Monitor Midwest Region Monitor Pacific Region Monitor Central Region Policy Midwest Region Policy Pacific Region Policy 12

Medicare Certifications 13

Certification is required upon admission 1 st re-certification is due before the 14 th day –(physician signature / date determines the due date for subsequent re-certifications) –Re-certifications are due every 30 days thereafter 14

Content of Certifications Must state the following: Reason for continued inpatient / skilled care Estimate of time for continued inpatient / skilled care Discharge plan Physician Signature / Date of signature 15

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 16

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 17

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 18

Role of HIM in Triple Certification / Re-Certification reporting Scanning of signed physician’s orders Reporting PPS Charting trends 19

Physicians’ Orders What makes up a complete physician’s order? Drug name / dosage Route Frequency Diagnosis for use Behavior manifestation Verification of informed consent 20

Lunch 21

Change of condition –Non-negotiable audit “MUST” be completed daily 22

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 23

Examples What are some examples of a change of condition? 24

Change of Condition Monitor & Policy Monitor (same for all Regions) Policy (same for all Regions) 25

Let’s review the audit form and identify where each item is located within the medical record……. 26

What would you change? Identify one step that would make your COC audit more qualitative? 27

MAR / TAR Must be monitored daily PRN Medications must have the following documentation: –Reason for administration –Effectiveness of medication 28

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 29

Diagnosis Coding Admission Diagnosis Form and Flow Sheet Presented by: Belen Dizon 30

Resolving Diagnosis Resolving Diagnosis process / flow sheet Presented by: Belen Dizon 31

Face Sheets Printing Face Sheets Admission & Discharge Presented by: Belen Dizon 32

Let’s share BEST PRACTICES 33

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. 34

Questions for discussion 35

Thanks for Attending 36