Articles Tagged With: Documentation
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Coping with Aftermath of COVID-19 Reimbursement Changes
Health plans issued many waivers during COVID-19 — for authorizations, for copays, and for telehealth. But patient access departments soon found the devil was in the details, with varying time frames and stipulations all coming into play. The result: A flood of denied claims. Learn how registrars are starting to sort through the mess.
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Finger-Pointing in Nurse Charting Is Opportunity for Plaintiff
Emergency nurses and physicians may not understand the liability implications of using charts to air grievances. A unified defense is recognized as the best approach for all defendants in ED malpractice claims, but finger-pointing notes make it difficult. Physicians and nurses should meet briefly before each shift to discuss the importance of teamwork, not only regarding patient care but also documentation.
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Documentation Can Determine Outcome of Missed Myocardial Infarction Lawsuit
Some charts might indicate there was chest pain and an abnormal ECG, but the patient was discharged with no explanation. Plaintiffs can use this to make a case the emergency physician missed classic presentation of myocardial infarction. Counter this allegation with specific documentation outlined here.
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Best Practices for Documenting Allergies
A good quality improvement project for 2021 would be to focus on bolstering the way the organization handles patients’ allergy histories.
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AAAHC’s Allergy Benchmarking Study Highlights Inconsistencies
In a recent study, investigators found allergies sometimes were not verified or updated at each visit, there was a reliance on using the acronym NKDA (no known drug allergies), without references to other allergies or sensitivities, and overall allergic reaction documentation was inconsistent.
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Discharge of Psychiatric Patients Is Legal Landmine for EDs
If a patient with psychiatric symptoms experiences a poor outcome shortly after discharge from an ED, allegations of inadequate medical screening are possible. Good documentation is the best protection against these allegations.
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Patients’ Easy Access to Records Means Complaints — and Chance to Avoid Litigation
Patients will no longer have to go through the discovery process during litigation to find out everything ED providers charted. Still, with patients reviewing all the clinical documentation, plenty of misunderstandings can happen.
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Pediatric Psych Visits Surging in EDs, Along with Medical Malpractice Risks
Before pediatric psychiatric patients are discharged from the ED, carefully document the visit and create a follow-up plan with a primary care physician or mental health professional. For patients presenting with suicidal ideation, a social worker or mental health clinician should develop a safety plan.
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Health Plans Want Proof It Was Necessary to Admit Patient
Work with utilization managers to understand why these denials are happening. Ensure clinical documentation is detailed enough to support inpatient level of care, and be sure to submit such evidence to the health plan while patients still are in house.
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The Basic Elements of Healthcare Reimbursement, Part 2
This month will continue the discussion of healthcare reimbursement by third-party payers. We began last month with a review of the diagnosis-related groups (DRGs) and associated terminology. We will continue by reviewing how medical records are coded followed by the new MS-DRGs implemented in 2007.