1. Admission/Discharge/Transfer (ADT), Coding & Error Resolution
RPMS EHR Inpatient

2. Admission/Discharge/Transfer (ADT)
Pre-implementation Check-List
PIMS ADT User’s Manual Jan 2009 ww.ihs.gov
PCC Supervisor’s Manual
IHS Chapter 3, HIM Manual
Present on Admission Site Parameters (PCC)

3. Things to Consider… Admit/Discharge orders (Date/Time)
Setup ADT Files (System Definition Menu)
Treating Specialty (OB, NB, GM, PEDS, OBS)
Room-Bed
Ward
Switch Bed (SWB)
Ward Transfer (WTX)
Attending physician (Change Provider when there is an order) PCH Provider Change

4. Things to Consider cont’d…
Against Medical Advice (AMA), Absent without Leave (AWOL), Patient on PASS
Discharge from Observation to Admit to acute care (time must be 1 minute after discharge from observation)
Intra-facility transfers (ward, treating specialty)
There must be an order from the attending physician to transfer from one ward to another, and from one provider to another provider (SWP)

5. Things to Consider cont’d…
Discharge
Time of Discharge (discharge orders and nursing discharge)
Correct discharge treating specialty (Mnemonic: IP)
Transfer to an IHS or non-IHS facility (build your own list)
Admission/Discharge Type/Source
IHS
UB-92
It is important to admit, discharge, and transfer in a timely manner!

6. Discharge Summary
PCC Inpatient Supplemental & Discharge F/U Record, IHS-485 (not required)
D/C Summary Tab v. Dictated DS
Discharge Summary template
Present on Admission (POA) Parameters
Acute Care v. Critical Access Hospital
POA (may be added to the template)
Importing data objects into the template (med list, labs, patient education codes)

7. POA Parameters
UPDATE PCC DATA ENTRY PARAMETERS SITE NAME: DEMO HOSPITAL
************************************************************************
UPDATE DEFAULT PARAMETERS (press enter): FORMS TRACKING? (Y/N) Y
UPDATE DISPLAY PARAMETERS (press enter): ASK OUTSIDE LOCATION? (Y/N) Y
Prompt for VISIT CREATION? (Y/N) Y ASK PROVIDER EVENT TIME? (Y/N)
PROMPT FOR MODIFIERS WITH CPT ENTRY? YES PROMPT FOR MODIFIER ON POV? N
ASK WALK-IN/APPT FOR CLINIC? (Y/N) Y
TYPE OF PROCEDURE CODING: ICD OPERATION CODING
Require Present on Admission (POA) for Hospital Stays? ?
Choose from:
DO NOT REQUIRE POA - CRITICAL ACCESS HOSPITAL
REQUIRE POA

8. Present on Admission Enter PURPOSE of VISIT: HTN
401.9 (HYPERTENSION NOS)
UNSPECIFIED ESSENTIAL HYPERTENSION
OK? Y//
PRESENT ON ADMISSION?:
Choose from:
Y YES
N NO
U UNKNOWN
W CLINICALLY UNDETERMINED
UNREPORTED/NOT USED (Exempt Codes)
PRESENT ON ADMISSION?: Y YES

9. Inpatient A Sheet 25 Admitting Diagnosis Insurance Coverage
DIABETES II/UNSPEC NOT UNCONTR (250.00
26 ICD POA Established DX
X DIABETES MELLITUS CONTROLLED
HYPERTENSION
CHR OBSTRUCTIVE PULMONARY DISEASE

10. Coding Use of Historical diagnoses (pertinent to the inpatient stay)
Adding a Diagnosis
E&M codes
Initial
Subsequent Days (Daily)
Discharge Management
Observation
Present on Admission Documentation (Coders enter codes/POA Indicators in ADT)
Final A Sheet vs. A Sheet worksheet
Inpatient Deficiencies

11. In-Hospital Visits Description
A patient seen by a consultant while in the hospital, e.g., receiving physical therapy treatment during a Hospitalization.
Link In-Hospital Visits to Hospitalizations (INP)
AUT Link In-Hospital Visits to Hospitalizations
MAN Manually Link In-Hospital to H Visit

12. TIU and ADT Reports
TIU SSD option should be used to monitor and track incomplete documents
Unsigned, Signed, by provider, Date range, Progress Notes, Discharge Summaries
ADT Reports Menu (RM)
Current Inpatient Listings
Provider's Incomplete Charts
Incomplete Chart Reports (ICR)
Listing of Coded A Sheets
Operators' Inpatient List
Incomplete Chart Statistics (ICS)
Inpatient Coding Status Report
Incomplete/Delinquent Statistics by Provider

13. Daily/Monthly Census Admissions & Discharges Sheet (ADS)
Monthly Census (M202) (CEN)
Yearly Census (Y202) (CEN)

14. Correcting Errors Changing Note Title
Retracting a Note (Justification documentation)
Reassign Note

15. Questions?