Medical Records – The Defense “Mitigating Liability”

July 11, 2013

Quality Auditing Process

FlowchartRisk Assessment Tool – Incident &

Wounds

Change of Condition

COC SBAR FormSBAR Flow Charts

Pressure Ulcer Monitor

Admit Audit & Instructions

Behavior Drugs

Antipsychotics Monitor & Instructions

Non-Antipsychotic Audit & Instructions

ID Team Care Conf Record

Fall RiskPressure Ulcer Risk

Aspirin RiskBleeding Risk

Bed-HoldDischarge Audit

Diabetic Monitor

Anticoagulant Audit

Audit Calendar Adm Oversight

Audit vs. TabulationFrom

QAA to QAPI

Updated ADMIN P&Ps

02005 (Notice of Privacy Practices)02030 (Business Associates)04015 (Elder / Dependent Adult Abuse)04030 (Informed Consent / Psychotherapeutic Med

(Antipsychotic) and Restraint Devices)08030 (Physician Extenders Physician Assistants Nurse

Practitioners)0A014 (Medication Documentation - KNS)

Updated HIM P&Ps0 4070 (Health Information Record Retention Guidelines)0 7001 (Notice of Privacy Practices)0 7050 ( Monitors - Completion Instructions)0 7050 (Admission-7-14-21-30 Day Combined Monitor)0 7050 (Behavior Psychotherapeutic Drugs Antipsychotic)0 7050 (Behavior Psychotherapeutic Drugs Non-

Antipsychotic)0 7050 (Behavior Psychotherapeutic Drugs Non-Antipsychotic

- INSTRUCTIONS)

Updated HIM P&Ps -2

0 8025 (Medicare Log)0 8030 (Medicare Certification - Recertification)0 8050 (Surveyor Electronic Health Record Protocol)0 A014 Medication Documentation – KNS0 B001 CareTracker Training Contract

Highlights on HIPAA

Texting