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Medicare trustees released their annual report in mid-March, and the picture they painted was not pretty. Costs are projected to triple over the next 75 years, and if the gap between revenues and expenditures doesnt narrow, at worst the fund will be depleted; at best, benefits will be significantly reduced.
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Who doesnt want to do things better? Reducing errors and completing more charts means increasing both the speed and the amount of reimbursement. But improving productivity is easier said than done.
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One day soon in a Kaiser Permanente facility near you, Kaiser patients will no longer be able to take a peek in the chart that the nurse leaves behind on the desk. No, its not because of the Health Insurance Portability and Accountability Act (HIPAA); Kaiser is going all digital, all the time.
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You should include the following items in your medical record documentation, according to Candace E. Shaeffer, RN, MBA, vice president of coding/quality management at Lynx Medical Systems in Bellevue, WA:
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If the cost of replacing a typical employee is up to twice the annual salary of that worker, why dont organizations spend more time and resources trying to retain their employees?
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Physicians are practicing more defensive medicine; Most appeals deal with coverage, not necessity; Bill to help hospitals fund immigrant care.
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If the nursing documentation in your emergency department is lacking key information, your facility may not be getting all the reimbursement it deserves. More ominously, inadequate nursing documentation can open the door for costly legal action down the road.
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Because the practice of placing a patient in restraints or somehow isolating that patient is scrutinized so carefully not just by the Centers for Medicaid & Medicare Services and the Joint Commission but by internal hospital committees and patients families as well its vitally important for you to be able to document what you did, why you did it, and how often you followed up.
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Its no secret that the fast-paced and often crowded environment at many emergency departments can pose problems not faced in other, more sedate levels of care. And its perhaps no surprise that many of the factors that cause inadequate documentation in the ED also can lead to medication errors.
