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


Comments

  • edited May 2016
    My thought on this is that it is something the case manager or UR staff
    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




  • This falls under case management at our facility. They contact the physicians directly.


  • edited May 2016
    This is the domain of the Care Management dept at our facility as well.

    Michelle Clyne, RN, BS
    Clinical Documentation Improvement Specialist
    Good Samaritan Hospital



  • edited May 2016
    Case Management handles patient status @ our facility and it's a never-ending job. I'm glad I don't have to do it anymore !!


Sign In or Register to comment.