E.H.R. Update

by Amy Guerra, HIM director

TMCA continues to move closer to our Electronic Patient Record-Horizon Patient Folder (HPF). We are currently in the first phase or the hybrid electronic chart model. Our current record consists of online documentation and paper documentation. A few electronically generated documents are no longer being printed for the chart. These documents include Nurses notes, eMARS and OB Documentation. The OR Management packet will soon follow in September 2010. The documents are available to be viewed online and can be printed indefinitely.

Currently we are working on our form preparation for HPF. The form will include two bar codes per document. One bar code will identify the patient and the other bar code will identify the document. When Horizon Patient Folder goes live the non-electronic documents will be scanned and incorporated into the electronic chart creating an online document. Physicians will be able to view and electronically sign any unsigned orders. Modified forms will be hitting the charts soon. Our current “Go-Live” date for Horizon Patient Folder is June 2012.

E-sign or E-Signature is a feature to authenticate your dictated reports.  It is also an option to sign your dictated reports. Currently, 40 percent of our medical staff uses this feature. In an effort to prepare physicians for HPF, the President’s Council has voted to make this a mandatory chart requirement beginning January 1, 2011. Please contact Anne Smith, PCI Coordinator at 303-873-5785 for access and training. H.I.M. staff are also available to assist you.

Sign, date and time all of your entries. The timing and dating of all entries is important for patient safety, regulatory requirements and legal purposes. Have you ever gone to court and had the lawyer ask you when you ordered the test or medication? It’s difficult to defend your case when the date and time are missing. Our recent Joint Commission prep session noted deficiencies in this area again, (60 percent compliance). To assist you, we placed time and date stamps in all the ICU Pods. How else can we help you?  Please let us know.

Signature Legibility  CMS has enacted a new regulation titled, Compliance Alert 31 for transmittal 327. The regulation states that if the payers can’t read your signature, they can deny the claim. This is serious! We can help you by ordering a printed name stamp for you. Please contact Amy Guerra, HIM Director at 303-695-2752 to place your order (or to print your name after your signature).

Recovery Audit Contractor (RAC Audits)  The national RAC audits are conducted by government contractors who are paid to review records and reclaim money. Since April 2010 we’ve had 54 charts requested. Most of these are for DRG (coding) compliance. So far we’ve done great. Seven percent of these charts required us to provide additional documentation. We’ve appealed these decisions and are confident of the reversal of the decisions. Moving forward, RAC will focus on your documentation, specifically, the medical necessity for admission and treatment.

Reminders:

• Please dictate the date on all your Consultations and Operative reports. It’s difficult to code and bill a record without this information. Please help us insure accurate coding.
• The current date and time should be used when signing all your entries including telephone or verbal orders.

Call me if you have any concerns or need assistance. I can be reached at 303-695-2752 or by cell at 720-641-3504.