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“HIM Workshop” Presented by:

Rhonda Anderson, RHIA

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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

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Teamwork

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

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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

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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

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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

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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

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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

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3520 Discharge Chart Monitor

• Central Region

• Midwest Region (same as Pacific)

• Pacific Region (same as Midwest)

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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)

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Audits

• Admission – Non-negotiable audit “MUST” be

completed for all admissions

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Admission Monitors & Policies

• Central Region Monitor• Midwest Region Monitor• Pacific Region Monitor

• Central Region Policy• Midwest Region Policy• Pacific Region Policy

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Medicare Certifications

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• Certification is required upon admission

• 1st re-certification is due before the 14th day – (physician signature / date determines

the due date for subsequent re-certifications)

– Re-certifications are due every 30 days thereafter

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Content of Certifications

• Must state the following: Reason for continued inpatient / skilled careEstimate of time for continued inpatient / skilled care Discharge plan Physician Signature / Date of signature

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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

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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

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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

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Role of HIM in Triple

• Certification / Re-Certification reporting

• Scanning of signed physician’s orders

• Reporting PPS Charting trends

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Physicians’ Orders

What makes up a complete physician’s order?

• Drug name / dosage • Route • Frequency • Diagnosis for use • Behavior manifestation • Verification of informed consent

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Lunch

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Change of condition

– Non-negotiable audit “MUST” be completed daily

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• 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

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Examples

What are some examples of a change of condition?

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Change of Condition Monitor & Policy

• Monitor (same for all Regions)

• Policy (same for all Regions)

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Let’s review the audit form and identify where

each item is located within the medical

record…….

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What would you change?

• Identify one step that would make your COC audit more qualitative?

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MAR / TAR

• Must be monitored daily

• PRN Medications must have the following documentation:– Reason for administration – Effectiveness of medication

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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

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Diagnosis Coding

• Admission Diagnosis Form and Flow Sheet

• Presented by: Belen Dizon

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Resolving Diagnosis

• Resolving Diagnosis process / flow sheet

• Presented by: Belen Dizon

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Face Sheets

Printing Face Sheets

Admission & Discharge

Presented by: Belen Dizon

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Let’s share BEST PRACTICES

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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.

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Questions for discussion

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Thanks for Attending