Hospital Systems...

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Hi ALL!
I am hoping someone can help me with an issue that arose at our facility recently. We are part of a 2-hospital system. When we look in our EMR, we see records from both facilities. So, when a patient is transferred from the other facility to us (higher level of care) we can access the record from their facility as well as ours. There are conflicting opinions regarding how this documentation from the other facility can be used. Can the H&P be used for coding? Progress notes? Only as a basis for clarification but not coding? Only if the MD specifically brings the records into our EMR as 'other documents'? Nothing?

Any clarification would be appreciated,

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • jschoonhovenjschoonhoven
    edited May 2016
    I have that same situation here. Patients are 'transferred' but technically it is a new admission here. We cannot code anything from the ED over there.
    The only time that we can use the H&P or a consult would be when the attending HERE "brings it into the record" by writing something like "see discharge note from ____" or, "see past medical hx in H&P by____"
    We still review the info ourselves so we can be alert to clarification opportunities if relevant in current chart.

    Janice

    Janice Schoonhoven RN, MSN, CCDS
    Clinical Documentation Integrity
    Manager- PeaceHealth Oregon West Network

  • Unknown
    edited May 2016
    Katy,
    We have that happen frequently, as we are a five hospital system. If the
    two hospitals share the same provider numbers it is considered one chart
    for us and the pdx starts with the initial admission at the first
    hospital and carries on with additional coding picking up as it occurs
    at the transfer hospital. If the two hospitals do not have the same
    provider numbers, it is considered two different admissions. I hope this
    helps. Thanks,
    Jamie Dugan RN
    Baptist Health System
    Jacksonville, Florida 32257
    Office 904-202-4345

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes! Thank you both. These are always two separate admission with different MD's caring for the patient. It is (was?) my understanding that documentation was NOT carried over into the 2nd admission but apparently, this is not agreed on by all staff members....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • jschoonhovenjschoonhoven
    edited May 2016
    It really is not a matter to be individually decided though. There are coding rules that cover this.
    Janice

    Janice Schoonhoven RN, MSN, CCDS
    Clinical Documentation Integrity
    Manager- PeaceHealth Oregon West Network
  • sabullocksabullock
    edited May 2016
    We treat as a new admission and each admission must stand on its own merit. We have a critical access hospital and rehab hospital - when the patient is transferred from either to the "mother ship" it is a separate admit even though we can see the info.
    Shelia
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Can you point me to them? It's actually our coding manager who thinks we can use the other facilities H&P. The actual coders are not. I have asked for details on her stance but am waiting for a response from her. I am hoping it is a misunderstanding but it has been stated several times and is confusing my CDIs.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • jolene.filejolene.file
    edited May 2016
    Hi Katy!
    In all the hospitals that I worked at, the chart stood alone unless the H&P was within 7 days of discharge & in that case could be used if updated by the attending physician and made a part of the current record.

    Your hospital Medical Staff Bylaws should address the H&P issue. Every record should have an H&P which may be from the other facility if it is updated by the attending. You may also reference the Medicare Conditions of Participation (MC-COP) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for their rules & regulations regarding usage of the H&P or other parts of the chart.

    Hope that is helpful.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

    IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.
  • Unknown
    edited May 2016
    Katy:

    We have six facilities and each facility is treated as its own entity, so we need separate documentation in the case of a transfer.

    Linda Haynes
    lhaynes@lhs.org
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