HIT 120 Chapter 4 Real Cases
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Dec 6, 2023
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Hit 120 Chapter 4 Real World Cases
Chapter 4
Health Record Content and Documentation
Megan R. Brickner, MSA, RHIA
Real-World Case 4.1
The hospital clinical documentation improvement (CDI) specialist reports to you, the HIM manager of
Anywhere hospital, that the hospital has been receiving reimbursement penalties. The physician
documentation is not appropriately identifying specific conditions that CMS has identified as hospital-
acquired conditions (HACs). In most cases, these conditions are present in patients before they are
admitted. However, physicians are documenting these conditions later in the patients’ stays, making it
appear that the patients have acquired these conditions from the hospital. The hospital is being financially
penalized because these conditions are considered to be preventable if the hospital follows national
treatment standards and guidelines.
Anywhere hospital has a robust EHR. Many documentation improvement initiatives have been leveraged
by the technological capabilities of the EHR. As the HIM manager, you wonder if something could be
done from a technology standpoint that could assist physicians with identifying, upon admission, those
conditions that are causing the reimbursement issue, and appropriately documenting the conditions.
Physicians appropriately capturing and documenting these conditions would demonstrate that the hospital
is following the national treatment standards and guidelines and the patients are not acquiring these
conditions in the hospital.
You assemble a multidisciplinary team consisting of physicians, revenue cycle representatives, HIM, and
information systems representation.
Real-World Case Discussion Questions
1.
Why do you think that CMS picked these conditions?
Infections acquired after being hospitalized to the hospital are known as hospital-acquired
conditions or infections. Most of them are avoidable, and their presence suggests that the
institution in question is not adhering to national standard practices.
2.
What is the benefit of developing an EMR solution for this issue?
EMR is critical to the safety and accuracy of patient records. If an EMR solution is implemented
for this issue, the hospital in question will have a higher chance of addressing the issue directly.
3.
How does the adherence to the treatment guidelines for the prevention of the conditions identified
as hospital-acquired relate to other pay-for-performance initiatives?
Adherence to treatment guidelines for the prevention of hospital-acquired illnesses is similar to other pay-
for-performance initiatives in that it is put up for the benefit of the patient, ensuring quality, efficiency,
and total value of health care.
Real-World Case 4.2
You are a HIM professional working in Anywhere hospital’s HIM department. You have been asked to
review physician documentation within the hospital’s new EHR system, implemented six months ago.
The goal of the review is to catch any documentation issues early and work with the appropriate hospital
leadership to fix those issues.
As you review the documentation in the EHR, you notice that physicians are utilizing the copy and paste
functionality available in the EHR, which allows them to select health record documentation from one
source or section of the EHR and replicate it in another source or section of the EHR. In one instance the
health record identifies a patient as a 65-year-old male (as identified during the registration process), but
in the progress notes the patient is described as a 25-year-old female who has given birth. Clearly, the
physician utilized the copy and paste functionality inappropriately and accidentally copied health record
information from the health record of a 25-year-old female and pasted that information into the health
record of a 65-year-old male.
This type of error could have patient safety concerns, as well as billing and claims issues, and the use of
this functionality could open up the facility to potential claims of fraud and abuse by the payer. You take
this concern to your leadership and a multidisciplinary group of hospital employees including HIM
professionals, nurses, physicians, and billing and revenue cycle employees to discuss and fix the problem.
There are mixed opinions about the copy and paste functionality. Some individuals feel this feature is a
time-saver and a productivity booster while others believe it only opens the hospital up to additional CMS
scrutiny.
Real-World Case Discussion Questions
1.
What should be considered when deciding whether or not to use the copy and paste functionality?
The first and most crucial question to ask is: what is the legality of the copy and paste function,
and what risks does it represent to the organization? Can the group explore other possibilities to
saving time with documentation now that they understand how to save time by using the copy
and paste function? The choice should involve multidisciplinary input from all EHR users,
particularly those who provide patient care and are most likely to employ copy and paste.
2.
What controls might be put in place related to the copy and paste functionality?
Once documentation decisions on the use of copy and paste have been made, the organization's
rules and procedures should be developed. If the business authorizes providers to continue
utilizing the function, chart audits could be used to check the documentation for erroneous,
outdated, redundant, false, or contradictory information. In addition, to reduce the amount of
modified data, the amount of free-text in the EHR should be limited.
3.
What alternatives to the copy and paste functionality are available?
One option to copying and pasting in the EHR is to use templates. A template is a pattern that
specifies the information to be collected and is used to capture data in a systematic manner. It
assists the provider in ensuring that critical information is not overlooked, and that data is
captured in a specified order and format. Other EHR functions that would help save time in
documentation and maybe decrease the need for free-text or copy-and-paste include using
selection boxes to allow the user to select a value from a predetermined list, drop downs, and
minimizing clicks or keystrokes.
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