Chyla Snedeker C803 task 4
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School
Western Governors University *
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Course
C803
Subject
Health Science
Date
Feb 20, 2024
Type
pptx
Pages
9
Uploaded by chyla.dunham
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History and Physical Documentation Compliance In Ohio
Chyla Snedeker
Student ID: 011709509
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H&P Standards: Ohio and The Joint Commission similarities
TJC Standards
Ohio Regulations
Time Frame
Must be completed within 24 hours of admission/readmission
Must be completed prior to any procedures
Can be up to 30 days old, if updated prior to procedure
Components
Chief Complaint
History of Present Illness
Medications
Allergies
Social History
Family History
Medical History
Surgical History
Lab/Test Results
Diagnosis/Assessment & Impression
Treatment Plan
Plan of Care
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H&P Standards: Ohio and The Joint Commission’s differences
TJC Standards
Ohio Regulations
Components
Habits (tobacco, alcohol, etc)
Heart
N/A
Lungs
Advanced Directives
Informed Consent
Prenatal Information
Evaluation of Developmental Age for Children
Performed By
No specific stated requirement
A properly credentialed member of the medical staff
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Justification:
The Importance of including social and personal history in the H&P
Holds key details that impact patient care
Helps to keep material and costs down
Saves time and leads to care efficiency
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Time Frames
TJC Standards
Ohio Regulations
Standard Admissions
•
Within 24 hours following admission
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Within 24 hours following admission
Surgical Admissions
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Prior to admission, but not more than 30 days before
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Prior to admission, but not more than 30 days before
Readmissions
•
The H&P must not be older than 30 days old and needs to be updated within 24 hours of readmission. This must be completed before any procedure requiring anesthesia. •
The H&P must not be older than 30 days old and needs to be updated within 24 hours of readmission. This must be completed before any procedure requiring anesthesia.
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Patient’s Chief Complaint
What is a Chief Complaint?
A chief complaint is a documented description of why the patient is seeking medical care
Why is documentation important?
Without a clear Chief Complaint, the service being rendered could result in in improper documentation and reimbursement (ie. Coded as “preventable service” or “unbillable”)
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Recommendations for Technical Improvements
To stay in compliance with both TJC as well as Ohio regulations I have the following EHR system update recommendations:
A policy requiring a patient’s H&P be completed within 24 hours of re/admission or before any medical procedure whichever is soonest
Requiring specifically credentialed medical professionals to perform the H&P
Ensure all components from slide 2 are included in H&P
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Plan
How to monitor
•
Invest in software
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Assign a Compliance Officer
How to stay current with national and state regulations
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Joint industry associations
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Regularly check the Office of Inspector General site
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Attend external trainings/ conferences
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References
History and Physical - Update Requirements | Critical Access Hospital | Provision of care Treatment and services PC. (2020). The Joint Commission. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment-and-ser
vices-pc/000002112/?p=1%20%20https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/
provision-of-care-treatment-and-services-pc/000002112/?p=1%203/3
Oachs, P., & Watters, A. (2020). Health Information Management: Concepts, Principles, and Practice (6th ed.). AHIMA. https://wgu.vitalsource.com/reader/books/9781584267577/epubcfi/6/68[%3Bvnd.vst.idref%3Dchapter020.xhtml]!/4/
2/2[ch20]/26/10/8[table020-3]/6/4/6/2/1:363[mat%2Cern]
Rule 3335-43-11 - Ohio Administrative Code | Ohio Laws
. (n.d.). https://codes.ohio.gov/ohio-administrative-code/rule-3335-43-11
Wise Health System. (202). Required Guidelines for History & Physical The Joint Commission (RC 01.01.01 EP4). Retrieved from Wise Health System: https://www.wisehealthsystem.com/medical-staff-orientation/guidelines-for-history-and-physical/#:~:text=Required%
20Guidelines%20for%20History%20%26%20Physical%20The%20Joint,a%20procedure%20requiring%20anesthesia
%20services%20%28including%20moderate%20seda
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