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

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Presentation on theme: "Medical Records – The Defense “Mitigating Liability” July 11, 2013."— Presentation transcript:

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

2 Quality Auditing Process Flowchart Risk Assessment Tool – Incident & Wounds

3 Change of Condition COC SBAR Form SBAR Flow Charts

4 Pressure Ulcer Monitor

5 Admit Audit & Instructions

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

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

8 Bed-Hold Discharge Audit

9 Diabetic Monitor

10 Anticoagulant Audit

11 Audit Calendar Adm Oversight

12 Audit vs. Tabulation From QAA to QAPI

13 Updated ADMIN P&Ps 0 2005 (Notice of Privacy Practices) 0 2030 (Business Associates) 0 4015 (Elder / Dependent Adult Abuse) 0 4030 (Informed Consent / Psychotherapeutic Med (Antipsychotic) and Restraint Devices) 0 8030 (Physician Extenders Physician Assistants Nurse Practitioners) 0 A014 (Medication Documentation - KNS)

14 Updated HIM P&Ps 0 4070 (Health Information Record Retention Guidelines) 0 7001 (Notice of Privacy Practices) 0 7050 ( Monitors - Completion Instructions) 0 7050 (Admission-7-14-21-30 Day Combined Monitor) 0 7050 (Behavior Psychotherapeutic Drugs Antipsychotic) 0 7050 (Behavior Psychotherapeutic Drugs Non- Antipsychotic) 0 7050 (Behavior Psychotherapeutic Drugs Non- Antipsychotic - INSTRUCTIONS)

15 Updated HIM P&Ps -2 0 8025 (Medicare Log) 0 8030 (Medicare Certification - Recertification) 0 8050 (Surveyor Electronic Health Record Protocol) 0 A014 Medication Documentation – KNS 0 B001 CareTracker Training Contract

16 Highlights on HIPAA

17 Texting


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