No problems were in 1Q2018 related to release of information from the Health Information Department and training of new employees/contract staff, however compliance with current law and HIPAA regulations need to be strictly adhered to requiring training, education and policy development at all levels. Actions: The indicators will continue to be monitored. III. Measure Name: Regulatory and Compliance Standards in Documentation Ensuring Fiscal Responsibility in Documentation and Billing Practices Indicator and Rationale for Selection 1Q2018 2Q2018 3Q2018 4Q2018 YTD Identification Data 100% 100% 63/63 63/63 Medical History, including chief complaint; 95% 95% HPI; past, social & family hx.; ROS, and 60/63 60/63 physical exam w/in 24 hr. conclusion and 3>24 hrs 3>24 hrs plan Summary of patient’s psychosocial needs as 75% 75% appropriate to the patients * 47/63 47/63 16>7 days 16>7 days Psychiatric Evaluation in patient’s record 89% 89% w/in 24 hrs. of admission 56/63 56/63 7>60 hrs 7>60 hrs Physician (TO/VO w/in 72 hr.) 95% 95% 111/117 111/117 Evidence of appropriate informed consent 91% 91% 61/63 61/63 Clinical observations including the results 100% 100% of therapy. 63/63 63/63 Nursing discharge Progress Note with time 78% 78% of discharge departure 49/63 49/63 Consultation reports, when applicable 95% 95% 131/144 131/144 Results of autopsy, when performed 97% 97% 61/63 61/63 Advance Directive Status on admission and SW 100% 100% follow up 63/63 63/63 Notice of Privacy 95% 95% 60/63 60/63 Chart Completion w/in 30 days of discharge 79% 79% date/discharge summary completed within 30 days 50/63 50/63 Discharge Packet sent to follow up 100% 100% provider within five days of discharge. 63/63 63/63 * The parameters for this measure will be changed to meet applicable goals as defined by the Director of Social Work. The current measure is more stringent than regulatory standards dictate.
No problems were in 1Q2018 related to release of information from the Health Information Department and training of new employees/contract staff, however compliance with current law and HIPAA regulations need to be strictly adhered to requiring training, education and policy development at all levels. Actions: The indicators will continue to be monitored. III. Measure Name: Regulatory and Compliance Standards in Documentation Ensuring Fiscal Responsibility in Documentation and Billing Practices Indicator and Rationale for Selection 1Q2018 2Q2018 3Q2018 4Q2018 YTD Identification Data 100% 63/63 100% 63/63 Medical History, including chief complaint; HPI; past, social & family hx.; ROS, and physical exam w/in 24 hr. conclusion and plan 95% 60/63 3>24 hrs 95% 60/63 3>24 hrs Summary of patient’s psychosocial needs as appropriate to the patients * 75% 47/63 16>7 days 75% 47/63 16>7 days Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission 89% 56/63 7>60 hrs 89% 56/63 7>60 hrs Physician (TO/VO w/in 72 hr.) 95% 111/117 95% 111/117 Evidence of appropriate informed consent 91% 61/63 91% 61/63 Clinical observations including the results of therapy. 100% 63/63 100% 63/63 Nursing discharge Progress Note with time of discharge departure 78% 49/63 78% 49/63 Consultation reports, when applicable 95% 131/144 95% 131/144 Results of autopsy, when performed 97% 61/63 97% 61/63 Advance Directive Status on admission and SW follow up 100% 63/63 100% 63/63 Notice of Privacy 95% 60/63 95% 60/63 Chart Completion w/in 30 days of discharge date/discharge summary completed within 30 days 79% 50/63 79% 50/63 Discharge Packet sent to follow up provider within five days of discharge. 100% 63/63 100% 63/63 * The parameters for this measure will be changed to meet applicable goals as defined by the Director of Social Work. The current measure is more stringent than regulatory standards dictate.
RiverviewQuarterlyReport1Q2018.docx