Description
SCENARIO
As the HIM Director, you recently posted a position opening for a Physician Incomplete Record Coordinator, and you have two department applicants who are both qualified. The applicants are excited to apply for a promotion. In order to ensure that you make a defendable hiring choice, you develop a tool to assess each applicant’s knowledge of medical documentation regulations.
This tool will help you identify the strongest candidate so that you can make the best decision by the end of the week. The tool has been started, but it needs additional information to assess each applicant during your interviews tomorrow accurately.
INSTRUCTIONS
First, review the provided resources below:
State Public Health Department Regulations
HIM3360-Deliverable-04-State-Public-Health-Department-Regulations.pdf
CMS Conditions of Participation for Medical Documentation
HIM3360-Deliverable-04-CMS-Conditions-of-Participation-for-Medical-Documentation.pdf
Department Procedure for Medical Record Documentation
HIM3360-Deliverable-04-LiveWell-Healthcare-s-Medical-Record-Documentation-and-Amendment-Guidelines.pdf
Physician Office Record
HIM3360-Deliverable-04-GCMC-Physician-Office-Record.pdf
Next, complete the Medical Record Documentation Tool
using the information in the above provided resources by:
HIM3360-Deliverable-04-Medical-Record-Documentation-Tool.rtf
Determine if the listed items numbered 1-24 in column A are covered by:
State Public Health Department Regulations (column B)
CMS Condition of Participation (column C)
Department Procedures (column D)
Record “yes” if it is covered or “no” if it is not covered in each empty field.
Assume that completed highlighted gray fields are correct.
Determine if the regulation sources (from column B, C, and D) are internal or external and document this for item numbered 25.
Determine if the physician office record meets the listed regulations in items numbered 26 – 28.
Record “yes” if the physician office record does meet the regulation or “no” if it does not meet the regulation.
Justify your determination by explaining your decision-making.
General Requirements
Uses professional language and tone with correct spelling, grammar, and punctuation in the Medical Record Documentation Tool.
Unformatted Attachment Preview
This is an EXAMPLE of one state’s health data requirements. Each state has requirements that are unique.
This is an EXAMPLE of one state’s health data requirements. Each state has requirements that are unique.
This is an EXAMPLE of one state’s health data requirements. Each state has requirements that are unique.
Illinois Department of Human Services
LiveWell Hospital
Global Care Medical Center
PHYSICIAN OFFICE RECORD
100 Main St, Alfred NY 14802
(607) 555-1234
EIN:
12-345678
BCBS PIN:
GC2222
BCBS GRP:
1234-P
NPI:
987CBA321
PATIENT INFORMATION:
#34900-Y
NAME:
YARROW, Melvin
PATIENT NUMBER:
ADDRESS:
12 Painter Street
ADMISSION DATE & TIME:
08-26-YYYY
CITY:
Alfred
PRIMARY INSURANCE PLAN:
Medicare
STATE:
NY
PRIMARY INSURANCE PLAN ID #:
573908899
ZIP CODE:
14802
SECONDARY INSURANCE PLAN:
Medicaid
TELEPHONE:
607-587-0101
SECONDARY INSURANCE PLAN ID #:
23562879
GENDER:
Male
OCCUPATION:
Retired
DATE OF BIRTH:
05-22-1932
NAME OF EMPLOYER:
POCase010
DIAGNOSIS INFORMATION
Diagnosis
Code
Diagnosis
1.
Onychomycosis
5.
2.
Hyperkeratoses
6.
3.
Type 1 diabetes mellitus with
7.
4.
polyneuropathy
8.
Code
PROCEDURE INFORMATION
Description of Procedure or Service
1.
Debridement, mycotic toenails (more than five)
2.
Reduction of digital hyperkeratoses, third and
fourth toes, right foot
3.
4.
5.
SPECIAL NOTES:
Date
Code
Charge
PHYSICIAN OFFICE RECORD
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
PATIENT NAME:
YARROW, Melvin
PATIENT NUMBER:
POCase010
DATE OF SERVICE:
08-26-YYYY
DATE OF BIRTH
05-22-1932
NURSING DOCUMENTATION:
MEDICATIONS ALLERGIES/REACTIONS:
CURRENT MEDICATIONS:
BP: NA
None
Not assessed at this time.
P: NA
R:
NA
T: NA
WT: NA
CC:
Mycotic toenails.
PMH:
Onychomycosis, diabetes type 1 with neuropathy, hyperkeratoses.
NOTES:
Patient has no other concerns today.
SIGNATURE OF NURSE:
OVS:
NA
Reviewed and Approved: Albert Molina RN ATP-BS:02:1001261385: Albert Molina RN (Signed:
8/26/YYYY 2:20:44 PM EST)
PHYSICIAN DOCUMENTATION:
Notes:
DIAGNOSES: Onychomycosis. Hyperkeratoses. Type 1 diabetes mellitus with
polyneuropathy.
Follow-up diabetic maintenance-care was provided with debridement of 10 mycotic
toenails and reduction of digital hyperkeratoses, third and fourth toes, right foot. Mr.
Yarrow has an ulcer on the right heel, which is under the care of Dr. Hoffman. When first
examining Mr. Yarrow this morning, dried blood was noted on all toes of the left foot. Mr.
Yarrow admits to attempting nail-care yesterday evening and apparently created a mild
laceration of the second toenail, left foot. There is an intact scab formation this morning.
No further treatment is needed.
The Plastizote chukka-style boots that were dispensed in April are comfortable, and
patient likes them very much. No other concerns.
Return to clinic in six weeks.
SIGNATURE OF PROVIDER:
Reviewed and Approved: H.W. Pocket MD ATP-BS:02:1001261385: H.W. Pocket MD (Signed: 8/26/YYYY
2:20:44 PM EST)
H.W. Pocket, M.D.
Internist
Sources
Deliverable 04 – Medical Record Documentation Tool
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Medical Record Documentation Tool
A.
B.
C.
State
Public
Health Record Regulation
CMS Condition
Health
(Locate and identify generally
of
Department
matching words; not exact
Participation
matching words to those listed
D.
Department
Procedure
Regulation
below.)
Confidentiality of Patient Records
Record entries cannot be back-dated
Medical record for each patient
evaluated, treated
Medical Record Department is
Adequately Staffed
Organized in a fashion that
facilitates location and retrieval of
records
A medical history and physical exam
Integrity of Authentication/signed
by responsible party
Medical Record Retention
Requirements
Addendums should be timely and
bear the current date and reason
A System for Coding and Indexing
Medical Records
Demonstrate a method to prevent
the alteration of an authenticated
record or method to properly
evidence a late entry
“Medical Record” includes written
notes, radiology, lab, etc.
Records compliant with HIPAA
Record contains a unique patient
identifier/number
Contain Notes to Justify Continued
Stay; Continuing Care
Records must be safeguarded against
loss and unauthorized access
Never obliterate entries using black
marker or correction fluid
Records must document any refusal
of services
Entries must be Dated, Signed,
Authenticated and Legible
Document the Course and Results of
Care Provided; Document with
factual data
Use only hospital approved
abbreviations
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Deliverable 04 – Medical Record Documentation Tool
22
23
24
25
Verbal (telephoned) Orders must be
Authenticated
Records of minors must be retained
for a period beyond the age of
majority
System in place to identify
incomplete or deficient records
Yes
Yes
No
Yes
No
Categorize the source regulation
in columns B, C and D as either:
• Internal
(regulation/guideline)
• External
(regulation/guideline)
Analyze Patient Office Record
Regulation
26. State Dept Health Regs: Each
patient has a unique identifier
27. CoP: Records must be
completed within 30 days of
service.
28. Department Procedure: All
General Documentation
Requirements
Yes or No:
Does it meet
the listed
regulation?
Justify the ‘Yes or No’ in previous column with
complete sentence(s) below.
Purchase answer to see full
attachment
