The Pros And Cons Of Missing Medical Records

In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.

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.

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

According to Chtourou (2013), a CDI program focuses on enhancing the accuracy of clinical documentation quality which requires a huge input from CDI specialists, heath information management professionals, coders and clinicians to collaborate together to review the quality of documentation reported/captured in order to ensure accuracy and complete of patient’s clinical encounter. As a healthcare provider, medical records that are incomplete or inaccurate often times, compromise the quality of care reporting and inevitably affect the clinical decision support system of the organization including the accuracy of reimbursement. This is reasonable since the CDI program has emerged as a new paradigm to meet the changing needs of maintaining a sound health record documentation across the healthcare industry (Hauger, 2014). Most of the CDI programs have to a great extent concentrated on boosting the Diagnosis-Related Groups (DRGs) installments by securing clinical documentation to support medical complications and co-morbidities (Hauger, 2014).

The value of CDI clinical documentation improvement (CDI) programs are important to any facility that recognizes the requirement of complete and accurate patient documentation. Documentation is very critical because it validates the care that was given. Furthermore, it shares important data to the caregiver and improve claims processing (Leventhal,2014). The three challenges are getting physicians to buy into the program, physicians are extremely busy so they are not connecting the dots on clinical documentation, and training the physicians to get them to understand they need to do better documenting (Leventhal,2014).

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

As a biller or coder, if it is not documented, it didn't happen that needs to follow to be able to give an excellent service to every patients. Documentation is the key to have an appropriate health patients result including demographics, health issues, and billing. “Consistent and complete documentation in the medical record for every patient is an essential component of providing quality patient care. This documentation is required to record pertinent facts, observations and findings, and must meet certain compliance standards.” If not documented that is not necessary to give any further diagnosis

Documentation records is related to the quality of patient care provided. It signifies the primary communication among multidisciplinary caregivers for efficient and effective intial treatment, for continuing care, and for the evidence that care and treatment occure. Regulatory agencies use the documentation as a means to measure the quality of services before granting accreditation or certification to healthcare organiztions. Some of those agencies include:

The potential sources of the problem that most of the healthcare institutions are experiencing could be that the healthcare organizations have not trained its staff or employees on how to do data entry as well as protection of the data that contains the information of the treatment cost as well as services. For that reason, the organizations should always train its staff on how to do data entry process and protect the data from being accessed by the unauthorized persons who could manipulate the data. The supervisors of the healthcare organizations are then supposed to be monitoring and also reviewing the process of entering data. That is to avoid the data inputted into the system being inaccurate. Another possible problem that they

Although the overall state of compliance for the organization is good, there are several areas that have been identified as “Priority Focus Areas” due to a past history of nonconformities. All these areas are related to Information Management and Record of Care, Treatment, and Services, in particular:

Although the overall state of compliance for the organization is good, there are several areas that have been identified as “Priority Focus Areas” due to a past history of nonconformities. All these areas are related to Information Management and Record of Care, Treatment, and Services, in particular:

The purpose of this policy is to establish a record management plan, including the retention and destruction of health records in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA), Public Hospitals Act (PHA) and the Personal Health Information Protection Act (PHIPA). Not only does it serve to identify records which must be maintained, but also specifies how long records must be retained and identifies the appropriate disposal process.

In order to void miscommunication between the doctor and patients, procedures should be setup to help the doctors collect basic information about the patients. This procedure includes getting patients fill out forms

Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to