Each “Physician Action” addresses only one thing – either the H&P or the op report. Only the mentioned one is a problem. You need to understand the requirements for the H&P and Op Report.
H&P must be completed and in pt’s medical record before the procedure can begin.
H&P can be done within the last 30 days prior to procedure, but must by updated by the physician prior to the procedure. This update must be dated and signed.
The op report must be dictated by the physician within 24 hours of the procedure.
Those are the things the staff member audited for.
1. Does the table make sense to you? Do you understand what each column is? Let me know if you do not…
a. Analyze the data: Which code is most common? (Which of the audit codes is most common? – 1, 2, 3, or 4?)
b. Is there one service that seems to be a problem? It looks like several services have a documentation problem, but one (OR) has the most. Some others appear to have problems also.
c. What can you conclude from the data? – What are the overall findings?
2. Establish a plan. What would you do to correct this problem? As members of the Medical Staff, the physicians have to meet certain requirements. They usually are not employees of the facility, but members of the medical staff established & approved by the facility, medical staff leadership, & board of directors. Usually a facility (HIM) will first remind the physician who is delinquent in documentation. If he/she doesn’t correct in a certain amount of time, they are reminded again and reported to the Medical Staff leadership – there may be a committee responsible for patient record documentation. They would need to be alerted. You should also keep administration informed. Perhaps you could plan a training meeting for the physicians to make sure they understand what the requirements are.Each “Physician Action” addresses only one thing – either the H&P or the op report. Only the mentioned one is a problem. You need to understand the requirements for the H&P and Op Report.
H&P must be completed and in pt’s medical record before the procedure can begin.
H&P can be done within the last 30 days prior to procedure, but must by updated by the physician prior to the procedure. This update must be dated and signed.
The op report must be dictated by the physician within 24 hours of the procedure.
Those are the things the staff member audited for.
1. Does the table make sense to you? Do you understand what each column is? Let me know if you do not…
a. Analyze the data: Which code is most common? (Which of the audit codes is most common? – 1, 2, 3, or 4?)
b. Is there one service that seems to be a problem? It looks like several services have a documentation problem, but one (OR) has the most. Some others appear to have problems also.
c. What can you conclude from the data? – What are the overall findings?
2. Establish a plan. What would you do to correct this problem? As members of the Medical Staff, the physicians have to meet certain requirements. They usually are not employees of the facility, but members of the medical staff established & approved by the facility, medical staff leadership, & board of directors. Usually a facility (HIM) will first remind the physician who is delinquent in documentation. If he/she doesn’t correct in a certain amount of time, they are reminded again and reported to the Medical Staff leadership – there may be a committee responsible for patient record documentation. They would need to be alerted. You should also keep administration informed. Perhaps you could plan a training meeting for the physicians to make sure they understand what the requirements are.