Operational Assessment

The ultimate goals of documentation are to provide accurate and timely clinical data and complete billing information for all hospital services provided to the patient. From admission through final billing to record storage, the professional staff of Health Systems Management Network can conduct an operational assessment of clinical-data generation, its documentation and the flow of that documentation.

CONCURRENT REVIEW OF DOCUMENTATION - includes a complete assessment of clinical data and documentation quality, timeliness and completeness.

DOCUMENTATION ASSESSMENT - develops a thorough understanding of the documentation process and staff practices to ascertain the consistency between services rendered and services billed, the severity of the case and the meeting or exceeding of all standards by final documentation.

NURSING DOCUMENTATION - determines the effectiveness of the nursing staff in assuring that complications, labs, meds and other ancillaries are documented correctly.

CODING/DRG ASSIGNMENT RETROSPECTIVE REVIEW - performed on a representativecase mix including those which fall into the window for rebilling.

ADMITTING - performed to assure accurate initial recording of information.

MASTER PATIENT INDEX - evaluates problems associated with the controlof accounts and the accuracy and availability of the medical record during subsequent patient visits.

RECORD COMPLETION - analyzes all procedures, policies and staffskills and behaviors that affect the entire post- discharge documentationprocess.

REGULATORY DOCUMENTATION REQUIREMENT - for example, establishment of procedures to meet new HCFA attestation regulations for ?account? mediators.

BILLING - determines how each step and function in the billing process contributes to the speed and accuracy of the final bill.

RECORD INFRASTRUCTURE - establishes how well the documentation management is supported by dictation and transcription, active and inactive medical record file management, inpatient/outpatient charting, and electronic systems.

Analysis and Recommendations

The results of our reviews will be analyzed for problems that may lead to quality of care issues, duplicated or unnecessary procedures, uncaptured charges, excessive time before billing and potential for lost revenue due to audit. A Continuous Quality Improvement Plan for clinical data and documentationwill result. Each goal of the recommendations will be listed as a critical path with benchmarks for completion by certain dates. This plan, althoughfirmly based on the facts discovered at your institution, will benefitfrom our wide experience in the industry. In close consultation with managersand staff, we will design system improvements and programs to correct deficienciesin clinical data and documentation. Priority and focus will be on revenueimprovement issues such as accuracy of coding and DRG assignments, thecompleteness of record at time of discharge, bill processing time, andthe ability of the documentation quality to meet or exceed standards.
We willrecommend staffing requirements if needed and detail educational needsfor existing staff members who will implement new practices and developany revised job descriptions, organizational structures or competency modelsrequired.
Staffand policies must be supported by efficient operational documentation processes,which in turn are supported by data processing systems. Our data processing experts will recommend appropriate changes in hardware and software.

Implementation and Evaluation

As required to assure a smooth transition to new procedures and systems, the professionals of Health Systems Management Network can lead or assist in the implementation of all recommendations. By using progress charts supplied in our final report, management will be able to assess progress and performance by task and responsibility.
Six to twelve months after submission of the management plan, we can perform a brief, iterative analysis designed to evaluate progress toward goals