It is important to keep your records complete and to review documentation. With this in mind Select Data is offering several tools such as this updated Free Medical Records/Chart Audit Tool. Simply download the attachment and enjoy the tool. If you find the tool useful or have comments let us know. We always appreciate the feedback.
Face To Face Encounters CY2011 Clinical Compliance
CMS was mandated by the Affordable Care Act to provide this encounter. You will be able to look on page 296 on the Final Rule to read the depth of it. But, essentially what CMS is stating is that the physician must see the patient within 90 days prior to the admission in a home health agency. And that means that also, in seeing that patient for that face-to-face encounter, that diagnosis or that reason for seeing that patient must be directly related to the home health referral. Now, if they don’t see them within 90 days prior to they must see them within 30 days after admission.
As of December 10, 2010 CMS is sending out a notice to the physician regarding this face-to-face encounter information. So the home health agencies are going to have to do a lot of education with physicians. It also requires then, that the physician provide this attestation that they have completed this face-to-face encounter, and it has to be attached to/or a part of the POC.
The face to face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. While the long standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition
Tracking PT/INR EvaluationPT/INR is a commonly used evaluation Lab test…
The Prothrombin Time (PT) evaluates the ability of the blood to clot properly. It is used to evaluate coagulation factors and bleeding likelihood of patients on anticoagulant therapy. This therapy is used to inhibit blood clots of patients who have had inappropriate clotting usually after a heart attack or after a deep vein thrombosis (DVT). The anticoagulant drugs must be monitored carefully so as to have a healthy balance between preventing a clot and causing excessive bleeding. The International Normalized Ration (INR) is used to monitor the effectiveness of the anticoagulant drugs.
Here is a handy tool to assist clinicians in monitoring not only the physician’s order but the follow up after the results are received.
This Infection Risk Assessment Tool offers an easy and quick review of client predisposing factors that aid in preventing infection. The clinician has the opportunity to evaluate education and training needs for patients and family members. It also allows for tracking of signs and symptoms, cultures, and outcomes including unscheduled hospitalizations and secondary infection development.
It is the goal of Select Data to frequently offer tools for home health leaders and clinicians. You should expect to see clinical and operational tools geared toward assisting to identify areas of preventive practice and opportunities for training and education as well .
Expect future tools to focus on Cardiac Status, Dementia, Depression, as well in addition to business and QI tools.
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