The Real-World Case

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.

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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 4.1


Why do you think that CMS picked these conditions?


What is the benefit of developing an EMR solution for this issue?



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?

Assignment 2: answer questions real world case 4.2; at least one page; cite textbook and or other sources; please see textbook below


Real-World Case 4.1


Why do you think that CMS Aaed these condions?


What is the bene<t of developing an EMR soluon for this issu Assignment 4: answer questions real world case 4.2 at least one page; cite textbook and or other sources. Please see textbook below

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 4.2


What should be considered when deciding whether or not to use the copy and paste functionality?


What controls might be put in place related to the copy and paste functionality?


What alternatives to the copy and paste functionality are available?

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