Articles Tagged With: Documentation
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Discharge of Psychiatric Patients Is Legal Landmine for EDs
If a patient with psychiatric symptoms experiences a poor outcome shortly after discharge from an ED, allegations of inadequate medical screening are possible. Good documentation is the best protection against these allegations.
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Patients’ Easy Access to Records Means Complaints — and Chance to Avoid Litigation
Patients will no longer have to go through the discovery process during litigation to find out everything ED providers charted. Still, with patients reviewing all the clinical documentation, plenty of misunderstandings can happen.
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Pediatric Psych Visits Surging in EDs, Along with Medical Malpractice Risks
Before pediatric psychiatric patients are discharged from the ED, carefully document the visit and create a follow-up plan with a primary care physician or mental health professional. For patients presenting with suicidal ideation, a social worker or mental health clinician should develop a safety plan.
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Health Plans Want Proof It Was Necessary to Admit Patient
Work with utilization managers to understand why these denials are happening. Ensure clinical documentation is detailed enough to support inpatient level of care, and be sure to submit such evidence to the health plan while patients still are in house.
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The Basic Elements of Healthcare Reimbursement, Part 2
This month will continue the discussion of healthcare reimbursement by third-party payers. We began last month with a review of the diagnosis-related groups (DRGs) and associated terminology. We will continue by reviewing how medical records are coded followed by the new MS-DRGs implemented in 2007.
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Recommended Elements of a Compliance Program
Provider Relief Fund compliance will require an extensive and far-reaching program, experts note.
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The Basic Elements of Healthcare Reimbursement — Part 1
Changes in healthcare reimbursement have occurred with lightning speed over the last two decades. Providers billed for services rendered and were reimbursed — with no checks, balances, or control over costs of care. Case management, as a care delivery model, followed a similar course. But as reimbursement changed, so did case management. This month we will begin our discussion of reimbursement, including the changes to case management as it evolved with reimbursement.
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Specific Items, if Well-Documented, Prove ED Met EMTALA Obligations
When CMS surveyors come on site to investigate an EMTALA complaint, the outcome often comes down to documentation.
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Suspicious Changes to ED Chart Become Central Focus of Malpractice Lawsuit
Once someone concludes an emergency physician changed the medical record after a bad outcome, credibility (and likely the case) is lost. If there really is a valid reason to correct the electronic health record, clinicians should consult their facility’s policies and procedures regarding such corrections.
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Many Charts Lack Any Evidence of Thorough H&P
Often, a portion of the history, assessment, or evaluation was handled, but for whatever reason does not make it into the emergency medicine record. This makes it appear as though a poor or incomplete assessment was conducted. Double check these items to see they are included.