Patient Status Documentation
I would like to obtain feedback regarding physician documentation and
patient status. With RAC audits, it has come to our attention that
documentation that specifically states why the patient has been changed
from observation to inpatient is optimal. Does anyone have any
strategies on how to engage their physicians into addressing the
patient's status in their documentation? Do your case managers have any
influence or participation in this process?
Thank you,
Lisa Taylor
RN, CDIS
Wooster Community Hospital
www.woosterhospital.org
330-263-8626
patient status. With RAC audits, it has come to our attention that
documentation that specifically states why the patient has been changed
from observation to inpatient is optimal. Does anyone have any
strategies on how to engage their physicians into addressing the
patient's status in their documentation? Do your case managers have any
influence or participation in this process?
Thank you,
Lisa Taylor
RN, CDIS
Wooster Community Hospital
www.woosterhospital.org
330-263-8626
Comments
should be looking at. As I recall, Medicare says that the physician
only needs to feel that the care cannot be accomplished in an outpatient
setting. But, when they don't meet UR criteria, then the provider needs
to be contacted by them as to why they made the change and request that
additional documentation.
Just my thoughts as a former case manager.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"To climb a steep hill requires a slow pace at first." -William
Shakespeare
Michelle Clyne, RN, BS
Clinical Documentation Improvement Specialist
Good Samaritan Hospital