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Feb 20, 2024

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Implications of mapping and documentation errors Shanta McGraw Southern New Hampshire University HIM-540-Q2399: Health Information Governance 23TW2 Elizabeth St James 1/7/2024

Implications of mapping and documentation errors Inaccuracies within a patient's medical file may lead to several issues. Error management as it occurs will enable appropriate training to be carried out to lower errors."In 2010, the National Library of Medicine (NLM) started a project to programmatically map SNOMED CT to ICD-10-CM by leveraging IHTSDO's cross-map," (Cartagena et al., 2015). The purpose of mapping the two together is to facilitate the coding process. One or more codes may be mapped, or there may be no mapping at all. "The Map will suggest candidate ICD-10-CM codes based on SNOMED CT codes and, if applicable, additional information obtained from the electronic patient record or direct user input," ( "FAQ SNOMED CT To ICD-10-CM Map" ,2018). The purpose of this mapping is not to be exhaustive. It is aimed to offer ideas for ICD-10 CM to be utilized. This is among the issues as well. Because it is not perfect, programmers will still need to exercise caution to make sure the right codes are being used. In accordance with ICD-10-CM coding principles, the sequence in which codes are encountered is significant when more than one code is present. It is crucial to check the codes because the ones that have been mapped are recommendations derived from the SNOMED-CT codes. "Mapping between SNOMED CT and ICD-10-CM using the I-MAGIC will become easier as individuals acquire medical terminology knowledge and coding experience," (McMillon, in 2020). Healthcare organizations utilize electronic health records, or EHRs, to gather and preserve patient medical data. An instrument used in clinical treatment, healthcare administration, and other domains to track clinical processes and compile a range of medical data from specific patients over time is the electronic health record, or EHR. Many patient-level data, like as vital signs, diagnosis, issue lists, medication information, and laboratory findings, are provided by EHRs. The National Academies of Medicine list a number of essential functions for

an Electronic Health Record (EHR), including population health reporting, order and outcome management, clinical decision-making, electronic health information sharing, electronic communication, patient support, and operational procedures. Patients who receive inaccurate registration information may have the following consequences: Test findings might fall into the wrong hands. Information from one patient may inadvertently end up in the account of another patient. If weights are shared between the pharmacy and registration systems, inaccurate doses may be administered. Errors can affect any patient. Medical mistakes are therefore expensive from a societal, economic, and human perspective. Diagnostic mistakes can be characterized as delayed, incorrect, or missing diagnoses discovered by a follow-up test or investigation. Either treating an ailment that wasn't actually there or delaying or treating one that was while the working diagnosis was ambiguous or incorrect cause the harm that follows. Either after the fact or not at all, payment is collected for services given. It's critical to convey accurate information. An incorrect insurance claim leads in a fee to the patient. Medical care may deteriorate if treatment is stopped due to outstanding debts. Ensuring the patient's name is spelled correctly on all papers ought to come easy. These kinds of mistakes are easily avoidable. A map from a clinical reference phrase to a classification system is meant to automate the categorizing process in an electronic health record (EHR). It is anticipated that the advancement of automated coding technology would have a major effect on conventional coding procedures, increasing productivity and enhancing data accuracy. Mapping establishes a connection between two categorization, nomenclature, or reference terminology schemes. No patient interactions or incidents were considered when creating the map. There must be a purpose behind each mapping between a source scheme and a destination scheme.

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Content issues in the patient health record include misspelled names, incorrect dates of birth, missing diagnostic codes, and incomplete signatures from physicians on all paperwork. The discharge report has a few typographical and grammatical errors. Documentation integrity is the correctness of the entire medical record. When filing reimbursement claims, it entails patient identification, authorship confirmation, revisions, record corrections, and audits of document validity. Rules and regulations demand that the patient's documentation be filled accurately and completely. If data is mapped improperly, it might be lost or corrupted while traveling to its destination. For the data map to be useful, it must be more than a single, static image from a certain point in time. It needs constant upkeep as your business grows and evolves. Data mapping is necessary for the success of many data processes. Erroneous analysis might arise from a single data mapping problem that spreads throughout your organization. Sally Pire is the first patient whose ICD-10 code is 19054-6. J18.9 is unspecified pneumonia.ICD-10 code for pneumonia caused by Mycoplasma pneumoniae is J15.7. The CPT code for a culture of Mycoplasma pneumoniae is 19054-6. This is not how ICD-10 and SNOMED should be mapped. The SNOMED code 233604007 is accurate for pneumonia disorder. This mistake may result in inaccurate data being recorded into the patient's electronic health record and billing issues. The two diagnoses are incongruent. Atherosclerotic cardiac disease is coded 125.10 on ICD-10, and cerebral disease is coded 65312002 on SNOMED. The patient may be put in danger by these coding mistakes, particularly if they get the incorrect prescription or course of therapy. Sam Seger, the second patient, had no ICD-10 or mapping in his medical file. For the patient, this can also be harmful since they could not get the

care that is required for their genuine illness. Additionally, if necessary tests and prescriptions are not submitted with the proper paperwork, the insurance company may refuse to pay. Documentation requirements are necessary for health records to guarantee the accuracy and consistency of the data. A number of regulatory organizations oversee the recording of patient health records and offer best practices recommendations for preserving data integrity. This document lists three of those regulatory agencies, along with some of their suggested best practices, instances of frequent infractions, and suggestions that may be useful in assisting in the abolition of those infractions. When making changes to the medical record, time/date and signatures must be recorded in accordance with Joint Commission (JC) requirements. The JC criteria include verbal order authorizations, consistent updates to the history and physical (H&P), drug management documentation, and appropriate audit integrity requirements for the medical record. This is blatantly against the patient records. To identify top performers and promote improvement, the National Committee for Quality Assurance (NCQA) "uses measurement, transparency, and accountability." NCQA design and modify measures for varied contexts and data sources, including electronic clinical quality measures and patient-reported outcomes measures" ("About NCQA",2020). NCQA is in favor of standardization. This regulatory organization also grants accreditation to insurance programs that report quality outcomes using the Healthcare Effectiveness Data and Information Set (HEDIS). There is no doubt that the records utilized in this study are unlawful. References Wolf ZR, Hughes RG. Advances in Patient Safety Error Reporting and Disclosure. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.

Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington: National Academy Press; 1999. About NCQA (2020). Retrieved from https://www.ncqa.org/about-ncqa/FAQ SNOMED CT to ICD-10-CM Map (2018). Retrieved from https://www.nlm.nih.gov/research/umls/mapping_projects/faqsnomedct_to_icd10cm.html Joint Commission (2009-2020). Retrieved from https://searchhealthit.techtarget.com/definition/The-Joint-Commission

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