Hardly a week goes by in the healthcare field without another announcement of a regulatory change, delay, or new initiative. Technology innovation seems to outpace our ability to absorb change or install the latest update on various systems and software applications.
At HCPro's Accreditation Specialist Boot Camp, we continue to receive questions about standing orders, protocols, and verbal/telephone orders. With spring on its way by the time this article is published, I thought a fresh look at these topics would be in order (no pun intended). Let's try to dispel the myths and go straight to what the regulations say and what is best practice to meet them.
HIM professionals are at the center of a shift from a paper-based to an electronic healthcare environment. As healthcare organizations work toward Meaningful Use attestation, there are standards that can help HIM professionals ensure that their electronic records are interoperable.
Organizations often struggle to finalize charts after discharge so they can be coded in a timely manner, but this process can be completed efficiently with direction from HIM professionals and coordination between departments.
Many hospitals and health systems include computer-assisted coding (CAC) systems as a strategic tool in their plan for ICD-10. CAC software is considered an antidote to the significant decrease in coder productivity anticipated with ICD-10.
RC.01.01.01, Content of the Medical Record, did not top the list of the survey findings for hospitals in the first half of 2014, according to the September 2014 issue of Joint Commission Perspectives. Nor was it on the list for critical access hospitals at all! However, 49% of hospitals surveyed received a requirement for improvement for this standard, primarily in the EPs related to timing and dating entries. This indicates hospitals are still using a lot of paper records. That said, the downward swing is encouraging as more and more hospitals fully implement the EMR.
