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If your documentation assurance program focuses on reimbursement alone, you're not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it's critical that the medical record accurately reflect the severity of illness and the services provided to your patients.
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Regular audits and continuing education are the keys to a successful documentation assurance program, says Liz Youngblood, RN, MBA, vice president, patient care support services at Baylor Health Care System in Dallas.
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"When I conduct an initial review of the chart, I read it from the beginning, like a story starting with the emergency department notes, through the history and physical and start building a story from a clinical standpoint.
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An emergency physician is managing an acute myocardial infarction, arranging for a patient transfer, sewing up a laceration, and putting in a chest tube, with 20 people still waiting to be seen in the waiting room.
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This is the first in a two-part series about the hidden risks and liabilities of medical helicopters.
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When a medical helicopter goes down, there often is more than one cause. Bad risk assessment, insufficient technology, and pilot error can combine to create a tragedy.
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If you are going to use medical helicopters, Don Maciejewski, JD, an aviation attorney with the Jacksonville, FL, law firm of Zisser Robison, recommends that risk managers be prepared for the worst. Make sure you are adequately insured to cover the payouts from a crash that kills five people on a nonurgent mission, he says.
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A hospital in New York is at the center of a storm of criticism, bad publicity, and possible criminal charges after an employee failed to report the gunshot wound of NFL star Plaxico Burress, as required by law.
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Emergency department physicians and nurses are deeply concerned about the ability of the nation's hospitals to deal with the medical implications of a radioactive dirty bomb or other terrorist attacks involving radioactive materials, according to a new study. Experts say the findings should be a warning to risk managers that action is needed.
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News: A man injured his neck and back after diving into the bottom of a shallow lake. He was transported to the hospital, where physicians became concerned that the man's central spinal canal had been compromised.
