What this means to me is as healthcare professional workers is we must follow the guidelines completely and accurately. It is very important to submit the right information being accurate so it doesn’t effect the reimbursement, public data reporting, quality and patient safety measurement, and research. Its very important that HIM professionals pay attention to details. “Coding professionals, regardless of their professional function or setting in which they work, should remember to first code to only what is supported by documentation in the chart and second ask for clarification if documentation is unclear.” (AHIMA) We are to remain professional when we code following and the procedures and guidelines and not make up our owns rules. Not
To the Public/Clients: Nursing is a profession that is responsible to patients and also to public. It is the right of the society to expect the best possible quality of care. So it is essential for nurses to stay abreast of current best practices. Nurses should have the knowledge of updated systems and modern equipments. Attending seminars and conferences, completing required competency tests, reading related books and articles, and complying with the required certifications are some of the ways to be proficient with the changes taking place in nursing field. Nurses should be aware of consumer’s increased level of knowledge and the increased accessibility to information from various sources (Hood, 2010, p. 307-308). Nurses are expected to be exercising reasonable judgment and deliver reasonable care to patients. Nurses have the obligation to act in the best interest of the patient. For example, recently one of my patients expressed her wish to change her code status. She stated that she is very tired because of her critical illness. She wants to go home to die peacefully. She told me that since her family is not listening to her wish she is frustrated. I informed her about hospice care at home and she requested to get more information from them. As a responsible nurse, I spoke with the physician and got the order for hospice evaluation for that patient. Finally, she was able to go home under hospice care. This shows the
The careful documentation and subsequent billing process within the course of a patient’s care is an important piece within the healthcare system as a whole. Proper documentation in a patient’s chart relating to any service or procedure is not only important for this patient’s future medical care, but for the facility to receive an accurate reimbursement for the services provided. Reimbursement is affected by every department within the hospital. Healthcare is a business in the long run, and inaccuracies within the reimbursement process will affect the financial stability of the hospital. If a department is mismanaging reimbursement data it could result
"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.
In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.
The first spoke, “adherence to code for nurses,” represents the need for nurses to follow the rules laid out for them. These could be scope of practice, rules associated with certain workplaces and following proper procedures. To be professional, a
My own work is influenced by national factors such and codes of practice, national occupational standards and legislation and government initiatives so that we the best quality of care and support to our clients. It is very important to understand and acknowledge all policies and rules so that you can do your job correctly and professionally. If we didn’t following these codes of practice then the level of care would be poor and people wouldn’t understand or know what good quality of care is.
Shadow charts were developed to gather data and information for additional departments and medical personnel that need access to part of a patient’s file or records. The original records should always remain in the patient’s primary chart allow copies may be available to ancillary departments that may need access to the information. The same level of confidentiality and security applies to the shadow charts. They must be in a secure location with access by authorized personnel only. Additional information that should be included in shadow charts is a formal recording process to document those who access the information. Furthermore, a consistent system of upgrading the
HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.
As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use
An accurate and specific documentation of universally accepted set of codes are important for the protection of healthcare providers as well as increased reimbursement for services received. These codes are for the validation of which services the patient received from their health care provider ( (Page, 2009). Having the correct codes in place insures the provider with the information needed by the health insurance carrier. Maintained by the AMA (American Medical Association), this universal numeric assignment is also used for developing guidelines for medical care review as well as data collection for medical education and research (Scott, 2013).
Apply accurate, complete, and consistent coding practices for the production of high-quality of healthcare data.
Answer: As a part of a high-reliably organization, I am committed to 200% accountability and safety as the number one goal. Over the past year as an Informaticist, I have consistently advocated for patient safety and safe workflows. As an example, a new staff endocrinologist made a request to update the Insulin Basal Bolus Correction order set that was not evidence-based. I met with the endocrinologist to review the current practice guidelines per America Diabetes and Endocrinology Associations. During our discussion. the endocrinologist did not realize that there was the ability within the order set to make the desired changes to individualize the care and orders
The majority of the time the use of HIM coders are involved in billing and reimbursements. However, coding specialists are important players within the healthcare industry.(Davis, 2014,2007,2002) They certify that providers maintain accuracy with coding procedures and government rules. (Davis, 2014,2007,2002) HIM functions and complex of regulatory requirements where coding can be very challenging. (AHIMA, 2016) The coders follow guidelines of the American Health Information Management Association AHIMA) Code of Ethics. (AHIMA, 2016) On the patient level, it is vitally important for the coder to code accurately because this information will trail the patient success throughout their course of treatment and beyond.
The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct
"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.