CLIN 2504 Documentation - Documentation Overview...

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Unformatted text preview: Documentation Overview Documentation Overview 1. 2. 3. 4. 5. 6. Importance Purpose Contents Format Standard procedures/Risk Management Legal aspects Section #1 learning objectives Section #1 learning objectives Importance of Clinical Documentation Recognize that the rate of growth in the healthcare industry has implications. Recognize the there are Federal and state requirements relating to healthcare documentation Understand that healthcare claims are closely scrutinized Realize that the chiropractic profession has a documentation problem Understand that health care records are required on all individuals evaluated or cared for. Healthcare Industry Healthcare Industry Clinical Documentation Clinical Documentation Department of Health and Human Services’ (HHS): Office of the Inspector General (OIG) Chiropractic Services in the Medicare Program; Payment Vulnerability Analysis Results of Report: 94% missing required elements 67% medically unnecessary/miscoded 40% maintenance 14% not medically necessary (other) 16% miscoded level 5% miscoded 6% missing documentation Sen Charles Grassley (R-Iowa) Addresses the National Chiropractic Legislative Conference regarding the Chiropractic Documentation Issues. Click on the picture above to view. Patient care documentation Patient care documentation State and federal statues Common law duty to create and maintain All individuals evaluated or cared for; Regardless of payment. This includes: Staff Family members Friends Colleagues Sporting events Patient Care Documentation Documentation of patient care is as important as the rendition of care itself Section #2 Learning Objectives Section #2 Learning Objectives Purposes of the Patient Health Record Define the patient health record. Recognize the primary purpose of the health record. Know the many reasons why we document patient information: Understand the importance of each purpose Patient Health Record Patient Health Record Business Document Legal record Patient protection Doctor protection Definition: Clinically pertinent information that is: Clear, concise, comprehensive, individualized, accurate, objective and timely Purposes of Documentation Purposes of Documentation Patient Focused Care Communicates Patient Health Information Patient care planning and continuity of care. Purposes of Documentation Purposes of Documentation Assessment of quality of care rendered Research and education Purposes of Documentation Purposes of Documentation Evidence of ‘standard of care’ Effective documentation may constitute the only objective evidence of whether care given to a patient met the practice standards or was substandard. Purposes of Documentation Purposes of Documentation Third party reimbursement Your records are the key to getting Reimbursed Purposes of Documentation Purposes of Documentation Informed consent Exam findings, dx Material risks of proposed intervension Expected benefits (goals) and prognosis Reasonable alternatives Solicit and answer patient questions Informed Consent form Purpose of Documentation Purpose of Documentation Referrals Your records project an image of your office to other professionals Professional communication with other professionals will ensure repeat referrals. Purposes of Documentation Purposes of Documentation Business document: Basis for justifying reimbursement Creates a database for assessing Quality Risk management Resource for research Resource for education Purposes of Documentation Purposes of Documentation Legal document: Documentation of patient health status Determines extent of injuries in accident or work comp cases Justify plaintiff’s request for damages Malpractice cases Protects patient in cases of negligence Protects Dr. in unjustified claims Section #3: Learning Objectives Section #3: Learning Objectives Contents of the health record: Recognize the clinician’s responsibility to ensure accuracy of the content Realize the permanency of the content Know all of the required contents of the patient health record Recognize the type of information that is expected in each category of the patient health record Contents of patient health record Contents of patient health record Important Points Clinician signature verifies completeness and accuracy Entries can not be altered once entered and signed Contents of patient health record Contents of patient health record Subjective Information Patient Intake form Patient General Information Questionnaire Chief complaint (CC) History of Present Illness (HPI) Health History Worksheet Case History_Sample Review of Systems (ROS) Stated in the pts own words, reasons why they are consulting the clinician Page 3 of the PGIQ by pt and clarified on history worksheet Past Hx, Family Hx, social Hx.clarified on history worksheet Contents of Patient Health Record Contents of Patient Health Record Objective Information Examination findings Chiropractic Screening Examination Problem focused Expanded problem focused Detailed Comprehensive Diagnostic Study Results Radiology reports Radiology Report Lab reports etc. Contents of Patient Health Record Contents of Patient Health Record Assessment Information Diagnostic impression Management Goals (short & long term) Prognosis Sample CMR Contents of Patient Health Record Contents of Patient Health Record Plan Information Patient management plan Adjustment and/or other care Patient education Active care recommendations including exercise Ergonomic and/or activity restriction/modification Any other health­related recommendations or supplies Diagnostic plan: additional testing, planned re­eval, OAT, referral etc. Contents of Patient Health Record Contents of Patient Health Record Follow Up Information Daily follow up visits (progress notes) Re­examinations Additional Test results Consultation reports Progress reports and copies of correspondence Section #4: Learning Objectives Section #4: Learning Objectives Format of Patient Health Record Understand the purpose of using a recognizable format. Realize that there are several types of formats that can be utilized Know the format that LUCC clinic system utilizes Understand basics of the SOAP format. Format of Patient Health Record Format of Patient Health Record Patient health information must be understood by others Narrative format Template format Prose form of literary composition Most computerized documentation systems Acronym format SOAP, PSP, SNOCAMP SOAP Format SOAP Format Subjective Objective Assessment Plan Initial visit (mega SOAP) Progress notes (mini SOAP) LC1000 Progress Notes SOAP SOAP Subjective Any clinically relevant information that the patient provides SOAP SOAP Objective Anything that can be measured or observed SOAP SOAP Assessment The clinicians opinions of what is going on based upon the subjective and objective information SOAP SOAP Plan Services provided (adjustment) Recommendation given to the patient Referrals Next scheduled appointment Care plan update Supplies provided Section #5: Learning Objectives Section #5: Learning Objectives Standard Procedures Recognize that the format utilized must be consistent. Understand that the system used must be organized and secure Know the requirements of all entries into the patient health record Know how to correct errors in the health record Recognize the need for standardized abbreviations in the health record Standard Procedures Standard Procedures Utilize a consistent format Utilize a filing system to maintain all patient records in an organized and secure manner. Patient health records should be easily retrievable Standard Procedures Standard Procedures A patient file should also include records received from other providers Ensure confidentiality of all patient health records. Standard Procedures Standard Procedures Documentation must be legible and indelible Standard Procedures Standard Procedures All entries must be added chronologically All entries must be signed or initialed All entries must be dated Standard Procedures Standard Procedures Each page in the patient health record must clearly identify the patient Each page in the patient file must clearly identify the doctor providing service Standard Procedures Standard Procedures Entries must be timely Standard Procedures Standard Procedures Entries should never be obliterated Leave no blank spaces or lines Error correction: single line, initial and date Standard Procedures Standard Procedures Only use standard abbreviations Have a standard abbreviation legend available Abbreviations List Section #6: Learning Objectives Section #6: Learning Objectives Legal Aspects of Clinical Documentation Recognize the owner of the health record Know the patient’s rights regard the record Know how to handle a patient’s request for records Know the requirements for storage and maintenance of patient records. Know what spoliation is Know the consequences of altering patient health records. Legal Aspects of Legal Aspects of Documentation Ownership of healthcare records The healthcare provider creating the record Patients are entitled to a copy of the PHI HIPAA Patients are entitled to have erroneous PHI corrected or their disagreement annotated. Dissolution of a practice Legal and ethical obligation to notify patients and ask them to provide names of a substitute healthcare provider. Keep originals until statutes of limitation expire. Legal Aspects of Legal Aspects of Documentation Patient request for records Transferring to another geographical area Provider may be moving Transferring to another doctor Applying for insurance Getting reimbursed from insurance Legal review Can charge for copy and mailing Always retain originals Records Release Authorization (click to view LUCC Legal Aspects of Legal Aspects of Documentation HIPAA regulations Properly executed authorization Document release of records Can charge for copying and mailing Always retain originals Legal Aspects of Legal Aspects of Documentation Release of Protected Health Information (PHI): Patient name, DOB, other identification Requesting doctor name, address, phone, fax (this can be pre­printed on your form), Doctor from whom you are requesting PHI, Specific records requested Patient signature or legal guardian date signed. Records Request (click to view LUCC form) Legal Aspects of Legal Aspects of Documentation Record storage State and federal requirements Professional regulatory boards Maintain original records Usually 7 – 10 years Minors Legal Aspects of Legal Aspects of Documentation Spoliation Intentional destruction of or alteration of records Unintentional Intentional Non­availability A jury will presume malpractice against a provider Adverse licensure action Civil and criminal action; form of fraud and obstruction of justice. Alteration of Patient Health Records Conclusion Conclusion Importance Purpose Contents Format Standard procedures/risk management Legal aspects References References Legal Aspects of Documenting Patient Care for Rehabilitation Professionals by Ronald W. Scott (Jones and Bartlett Publishers) Recommended Clinical Protocols and Guidelines for the Practice of Chiropractic, Appendix; published by the International Chiropractors’ Association Clinical Documentation Manual; published by the American Chiropractic Association ...
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