HEALTH INFORMATION / RECORD SYSTEMS “Non-Negotiable” Monitoring Systems Process for CQI – Phase I

Presenters Diane Settle, RHIT Khaleelah Wagner, RHIA Director of Operations, AHIS Rhonda Anderson, RHIA President, AHIS 2

Date & Time Date:xx/xx/xx Time – Attend one session AM PM 3

Objectives Participants will identify: Health Information / Record System identified as Phase I “non-negotiable” audits Establish the Med Rec CQI monitoring process – Phase I The calendar to “watch-use” – Phase I of the CQI monitoring process The stand up reporting & follow up system The weekly & monthly trends and report to CQI 4

Example I 5

Admission Admin and readmit daily, as applicable – 24,72, 7, 15, 21 days Take Admit Monitor to standing up and identity follow up until 100% or resident discharges Pay attention to risks!!! i.e. neuro, new infection 6

Admission-1 Re-admission greater than 24 hours – same process >> for record content – timeliness - accuracy Audit form – see Example I. If added notes needed to explain what is needed, utilize the comments page 7

Admission -2 8

Admission -3 9

Discharge When to complete: Keep Discharge Medicare and Final Discharge Monitor for the facility & Rockport UR/Medicare Reviewers Discharge from Medicare Discharge from Medicare and facility Discharge from Medicare and staying in facility (keep the Discharge from the Medicare Monitor until resident is discharged from facility and use the same monitor) 10

Discharge -2 When to complete: Keep in the overflow folder or notebook – alpha order and pull the Medicare Discharge Audit and complete remainder of the monitor at discharge Comments POLST – Needs to go with resident to hospital and home – ensure it is copied after completed on admission – after Dr. sees resident & completes the POLST – include in active chart 11

Discharge -3 12

Discharge -4 13

Change of Condition Allow 24 hours – for Review: Any change for the resident: medication, i.e., elevated temperature, resident found on floor Skin condition changes – increase in Psychotherapeutic Drug, Pain, not previously identified “ACTION” -- Follow up 24/48/72 hours, until complete, as applicable System to identify C of C >> 24 hour log & telephone orders 14

Change Of Condition -2 Take C of C report to standup Discussion at standup re: action and follow up Report follow up next day until documentation ??? resolved 15

Change of Condition -3 16

Change of Condition -4 17

Monitor Follow Process Binder at Nursing station Follow up process and managing the follow up Or ??? Avoid copying individual nurse Monitor and lots of paper – HIPAA concern Concerns re: late entry 18

Stand Up Flow Process – Monitor Focus Monitor Calendar used Identify Change of Condition Identify items from Monitor needing follow up Identify items not completed from prior Monitors Stand up “staff” indicate who is to follow up following Monitor and response Focus on 19

Stand Up Flow Process – Monitor Focus -2 20

Certs & Recerts Complete for each Cert/Recert due Track for timeliness and completion Statement of continued need for the reason for skilled care (not just restated on an order) All portions of the Cert/Recert must be complete, dates accurate based on required due dates Delayed certs should be used rarely – but an option 21

Certs & Recerts -2 Signature must be legible Signature Sheet – if you use one??? Without legible signatures – claims may be denied 22

Certs & Recerts -3 23

Medical Nutritional Therapy Dietician provides a copy of all RD recommendations for follow up Review the recommendations from the Dietary Consultant Follow up on documentation recommendations to determine if they were addressed by Nursing with physician and follow up (as applicable) Report status at stand up and CQI 24

Medical Nutritional Therapy -2 25

Medical Nutritional Therapy -3 26

Medication Quantitative MAR/TAR narratives MAR/TAR – Monitor – Daily for last 24 hours – One (1) sheet per each day Daily with immediate follow up Include name of Nurse CQI purposes – late entries = documentation and verify medication 27

Medication -2 28

Medication -3 29

TAR & MAR Identify date audit is “FOR” what that means to the MRD Narcotic Book monitoring Audit of PRNs for MAR/TAR Identification of Medication Cert Who receives copies (cc:) of Monitor Legalities & Risks CQI focuses 30

TAR & MAR -2 31

Physician Visit & H&P Use the Physician Visit and H&P log for now until we implement the Clinical Record Monitor monthly. (If you already use such or a General Update Log – continue to use it – must contain visit dates and H&P due dates and monitoring.) 32

Physician Visit & H&P -2 33

Health Information / Record Department Evaluation The Key to managing a department A tool for evaluating the skills of the HIM/Record Director and Staff Includes the basic minimum at Phase I for Dept. Evaluation A guide – HIM/Record Consultant quick reference tool for future visits 34

Health Information / Record Department Evaluation -2 35

Questions and Answers!! When do I start or revise the process I currently have, if needed? Who will be my resource? Diane Settle or her at ROCKPORT HealthCare Services; –cell Anderson Health Info. Systems at and w/reference to Khaleelah Wagner or Rhonda Anderson 36

THANK YOU Thanks for your great work; your work for tomorrow and the support of our clinical team. 37