Standard Location YES. Activities of Daily Living section completed. VMG Clinic Intake Form
|
|
- Duane Morgan
- 5 years ago
- Views:
Transcription
1 Tracer Record Review - Outpatient Only updated: 3/21/2016 Data Definition Tool The Tracer Packet is to be completed in each outpatient area by the manager or designee on a monthly basis. It is suggested that the manager does not complete a packet for his/her own area. Tracers are due on the last day of the month following the review (example: July Tracer due July 31). Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. Outpatient Units: Monitor at least 1 patient record per month using the Tracer Record Review Outpatient Tool. ADMISSION 1 Medical Record Number: 2 Functional screen complete PC ; PC If functional screen positive, plans for follow-up documented Standard Location YES EP 8 PC Follow-up for Positive Intake Screen in PT, OT, ST sections. Activities of Daily Living section completed. Positive screen follow up documented on form; NA=negative screen or preexisting condition (i.e., blind, cerebral palsy, or ADHD) 4 Nutritional screen complete PC , EP 4; PC EP 7 Nutritional screen completed. 5 If nutritional screen positive, plans for follow-up documented. PC EP 4; Follow-up for Postive Intake Screen Positive screen follow up documented on form ; or negative screen = NA 6 Pain screen complete PC EP 1 & 2 Pain screen completed
2 7 If pain screen positive, plans for follow-up documented PC ; PC EP 3 8 Abuse screen complete PC If abuse screen positive, plans for follow-up documented PC EP5, 6, & 7 Follow-up for Postive Intake Screen. Positive screen (option C and >3) follow up documented on form; or negative screen = NA Social Environment screen completed. Positive screen follow up Follow-up for Postive documented on form; or Intake Screen. negative screen = NA 10 Falls screen complete PC EP 1 11 If falls screen positive, plans for follow-up documented PC Learning needs/education screen complete PC EP 1, 4 & 5 13 If education screen positive, plans for follow-up PC documented EP Preferred language for discussing health care documented. PC EP 1 PROBLEM LIST (OP Only) 15 Complete (diagnoses, procedures, allergies, meds) RC Updated at every physician visit RC EP 3 VMG Assessment & Follow-up. VMG Assessment & Follow-up.. VMG Assessment & Follow-up and the Starpanel outpatient white board StarPanel - click on Problem list. StarPanel - click on Problem list. Falls screen completed for pts >/= 65 yrs. Positive screen follow-up documented on form. Educational screen completed. Positive screen follow-up documented on form or negative screen = NA Documented All component fields are completed in StarPanel. Date of problem list matches most current physician visit. PATIENT EDUCATION 17 All "teaching" fields complete, as appropriate (excluding pain management) PC Follow-up for Positive Intake Screen All teaching fields are completed as appropriate.
3 18 Documentation by all disciplines, involved in the patient's care, treatment, or services. MEDICATION ADMINISTRATION 19 "Do Not Use" Abbreviations are NOT found in the MR on date of review? 20 Supporting documentation (diagnosis, condition, or indication) for every order for "current" medications. PC EP 5 IM EP 3 MM EP 9 21 Order present for each medication administered. RC Are orders for PRN medications specific such that there is no therapeutic duplicatoin (multiple options for a specific indication? OPERATIVE & OTHER PROCEDURES 23 RI Consent form present and signed, dated and timed. EP Type of sedation/anesthesia included on consent form. RI EP 13 Same as above. Paper and individual discipline notes All entries in the medical record on date of review including medication orders, problem list, flowsheets, progress notes,etc. Physician orders, H&P, progress notes StarPanel: medication administration; progress notes Medications list Consent Consent form/ Anesthesia Care Record Signature(s) & initials are present for appropriate disciplines. No " Do Not Use" abbreviations are found in the medical record on the date of review. Diagnosis, condition or indications for use are documented. Order present. Review patient's current PRN medication orders for therapeutic duplication. There should not be two orders that have the same instructions for when to administer (e.g., prn pain, prn nausea, prn for agitation). completed, signed, dated, and timed. Type of sedation/anesthesia consent is documented
4 25 Provider history and physical (H&P) completed and documented prior to procedure? (May use previous H&P documented within 30 days prior or 24 hours after admission or registration that includes an update. The update includes an examination and any changes to the patient's condition.) PC EP5; H& P form H&P on record prior to procedure/surgery and w/in appropriate timeframes: 26 Pre-procedural education documented before operative or high-risk procedures or before moderate or deep sedation or anesthesia. PC On sedation form Documented 27 Patient's conditionis re-evaluated before administering moderate or deep sedation. PC EP 8 Sedation & Analgesia Record, Anesthesia record ASA class and Pre-Sedation status completed for moderate or deep sedation. 28 Pre-Procedure Checklist is completed? UP "Time Out" documented before procedure. UP EP 5 Pre-procedure checklist Area specific documentation systems. Sedation/Analgesia form All fields completed, as appropriate. Completed including date and time.
5 30 Immediate Post Operative/procedural Note is present and includes the following: 1. Name of surgeon, proceduralist and assistants; 2. Procedure(s) performed and description of the procedure; 3. Findings 4. Estimated blood loss; 5. Specimen(s) removed, if any. 6. Postoperative diagnosis; RC EP 7 Post surgical progress notes All elements are documented in the record before the patient moves to the next level of care irregardless of physical location. NA=Operative/Procedural report completed before the patient is transferred to the next level of care or if the proceduralist accompanies the patient from the procedure room to the next level of care, the note can be written in that unit or area of care. 31 The Operative/Procedural report is dictated or electronically entered in the pt record within 24 hrs of the procedure and includes: 1. Patient s name and unit number; 2. Date of procedure; 3. Name of surgeon, proceduralists and assistants; 4. Pre-operative diagnosis, 5. Postoperative diagnosis; 6. Anesthetic agent used; 7. Description of the techniques and procedure; 8. Description of the findings; 9. Estimated blood loss; 7. Specimen(s) removed, if any; 8. Any laboratory or diagnostic procedure ordered; 9. Complications, if any; 10. Condition of patient. RC EP 5 & 6 CMS (b) Surgical / procedure Report All elements are documented in the report and dictated or electronically entered within 24 hours of the procedure. The attending physician has signed the report within 14 days of the procedure.
6 32 For operative or high-risk procedures and/or the administration of moderate or deep sedation or anesthesia, patients are discharged from recovery area by LIP or by criteria. (Procedural Areas) PC Discharge instructions form present and complete PC EP 8 34 Patients who receive sedation or anesthesia are PC discharged in the company of an individual who EP 6 accepts responsibility for the patient. Discharge criteria documentation. Discharge instruction form On sedation form Discharge criteria documenation completed, dated, and timed. Documentation present.
IP = Inpatient OP = Outpatient Standard Location YES No. HED: Admission History tab or paper record Admission /History/ Discharge form
Tracer Record Review - ECT-Periop Only 9-30-2016 Data Definition Tool The Tracer Packet is to be completed in each Periop area by the manager or designee on a monthly basis. It is suggested that the manager
More informationPC EP 2 & 6 PC EP 4 & 5
Record Review Inpatient Only 3/10/2016 Data Definition Tool The Tracer Packet is to be completed in each inpatient unit by the manager or designee on a monthly basis. It is suggested that the manager does
More informationPC EP 4; PC EP 7. (Outpatient Only) If nutritional screen positive, plans for follow-up documented.
Dialysis - Patient Documentation & Observation Tool Data Definition Tool This audit is to be completed by the manager or designee on a monthly basis. "Dialysis - Patient Documentation & Observation Tool"
More informationJoint Commission quarterly update Medical record documentation guide and medical record reviews
April 2016 HIM Briefings Joint Commission quarterly update Medical record documentation guide and medical record reviews Jean S. Clark, RHIA, CSHA Our readers have been asking for an updated medical record
More informationCommunity Health Network, Inc. MEDICAL STAFF POLICIES & PROCEDURES
Community East Community South Community North TITLE: Medical Record Chart Requirements The medical record of care comprises all the data and information about a patient s visit. It functions as both a
More informationMedical Staff Rules & Regulations Last Updated: October University Hospital Medical Staff. Rules & Regulations
University Hospital Medical Staff Rules & Regulations 1 UNIVERSITY HOSPITAL MEDICAL STAFF RULES AND REGULATIONS The Medical Staff shall adopt Rules and Regulations as may be necessary to implement the
More informationThe University Hospital Medical Staff. Rules And Regulations
The University Hospital Medical Staff Rules And Regulations - 1 - UNIVERSITY HOSPITAL MEDICAL STAFF RULES AND REGULATIONS The Medical Staff shall adopt Rules and Regulations as may be necessary to implement
More informationMONITORING AND SUPPORT OF PATIENTS RECEIVING MODERATE SEDATION AND ANALGESIA DURING DIAGNOSTIC AND THERAPUTIC PROCEDURES POLICY
POLICY MONITORING AND SUPPORT OF PATIENTS RECEIVING MODERATE SEDATION AND ANALGESIA DURING DIAGNOSTIC AND THERAPUTIC PROCEDURES POLICY A policy sets forth the guiding principles for a specified targeted
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationEP Review Project: The Joint Commission Deletes 225 Hospital Requirements
PR Review Project: The Joint Commission Deletes 225 Hospital Requirements Project REFRESH (see related articles on pages 1 and 3) includes a project first announced in the December 2015 Perspectives: the
More informationSTANFORD HEALTH CARE Medical Staff Rules and Regulations. Last Approval Date: December 2017
STANFORD HEALTH CARE Medical Staff Rules and Regulations Last Approval Date: December 2017 The Medical Staff is responsible to the Stanford Healthcare (SHC) Board of Directors for the professional medical
More informationSedation/Analgesia by Non-Anesthesiologists. THE UNIVERSITY OF TOLEDO Approving Officer:
Name of Policy: Policy Number: 3364-100-53-11 Department: Hospital Administration Medical Staff ^HEALTH THE UNIVERSITY OF TOLEDO Approving Officer: Chief Executive Officer - UTMC Responsible Agent: -Chief
More informationCRITICAL ACCESS HOSPITALS
Are anesthesia services and post-anesthesia services medical director(s) qualified in terms of education, experience and competency as determined by the hospital medical staff and appointed by the governing
More informationSec Disconnect Go to End Forward Sec Next Report Go To
Effective 3/15/04 escription DICTATION SYSTEM FOR INPATIENT HISTORY & PHYSICALS, DISCHARGE SUMMARIES, DELIVERY (NORMAL) NOTES OPERATIVE REPORTS DIAL 3-4000 LISTEN FOR VERBAL PROMPTS. ENTER: First 5 digits
More informationHigh 5s Project: Action on Patient Safety. SOP Flow Charts. 20 th International Forum on Quality and Safety in Healthcare April 2015 London, UK
High 5s Project: Action on Patient Safety SOP Flow Charts 20 th International Forum on Quality and Safety in Healthcare 21-24 April 2015 London, UK Performance of Correct Procedure at Correct Body Site
More informationInstitutional Handbook of Operating Procedures Policy
Section: Clinical Policies Subject: General Procedures Institutional Handbook of Operating Procedures Policy 09.13.09 Responsible Vice President: EVP and CEO Health System Responsible Entity: UTMB Health
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More information11/1/2016. Hospital Breakfast Briefing: Provision of Care, Treatment & Services. Publications and Record Restrictions.
Hospital Breakfast Briefing: Provision of Care, Treatment & Services November 3, 2016 Steve Chinn, DPM, MS, MBA Consultant Joint Commission Resources 1 Hospital Breakfast Briefings Part 10 Disclosure Statement
More informationProtocol/Procedure XX. Title: Procedural Sedation/Moderate Sedation
Protocol/Procedure XX Title: Procedural Sedation/Moderate Sedation A. DEFINITION Procedural Moderate Sedation/Analgesia is a drug-induced depression of consciousness during which patients respond purposefully
More informationReview for Required Monitors
Review for Required Monitors The Joint Commission Hospital Accreditation Manual, 2009 Medicare Conditions of Participation, Hospitals Update: February 2009 Indicator / Monitor Restraint, Medical (non-specific
More informationInvestigation Outline for a Reportable Incident Non-Hospital Surgical Facility
Investigation Outline for a Reportable Incident Non-Hospital Surgical Facility MANDATORY NOTIFICATION The Medical Director shall notify the College of Physicians & Surgeons of Alberta (Accreditation Department)
More informationBeltway Surgery Centers, L.L.C.
MEDICAL STAFF RULES AND REGULATIONS ARTICLE I. PROFESSIONALISM 1.1 These rules and regulations are intended to provide comprehensive information to members of the Ambulatory Surgery Center in order for
More informationRULES AND REGULATIONS OF THE BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS
RULES AND REGULATIONS OF THE BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS Approved by the Executive Committee of the Medical Staff, November 5, 2001. Approved and adopted by the Board
More informationPatient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult
Title: Documentation of Clinical Activities by UNMH Medical Staff and House Staff Applies To: UNM Hospitals Responsible Department: Office of Clinical Affairs Updated: 05/2016 Policy Patient Age Group:
More informationAnesthesia Services Policy
Anesthesia Services Policy Policy Number Annual Approval Date 3/14/2018 Approved By Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare Medicare
More informationG: Surgical. College of Licensed Practical Nurses of Alberta, Competency Profile for LPNs, 3rd Ed. 67
G: Surgical College of Licensed Practical Nurses of Alberta, Competency Profile for LPNs, 3rd Ed. 67 Major Competency Area: G Surgical Competency: G-1 Surgical Nursing Date: June 1, 2015 G-1-1 G-1-2 G-1-3
More informationNURSING GUIDELINES TO PROCEDURAL SEDATION Finalized 1/18/2012 Procedural Sedation Task Force
Intention (responsiveness) Responds normally to commands Responds purposefully to verbal commands/or light touch DEEP Responds to pain Reflex withdrawal No response Anticipated Outcomes (Airway, Cardiovascular)
More informationEmpire BlueCross BlueShield Professional Reimbursement Policy
Subject: Global Surgery NY Policy: 0012 Effective: 02/01/2014 05/31/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria
More informationUniversity of Virginia Medical Center Clinical Protocol for Moderate or Deep Sedation/Analgesia in Adult Patients
A. PURPOSE University of Virginia Medical Center Clinical Protocol for Moderate or Deep Sedation/Analgesia in Adult Patients Sedation and analgesia are used alone or in combination to facilitate the performance
More informationProposed Standards Revisions Related to Pain Assessment and Management
Leadership (LD) Chapter LD.0001 Proposed Standards Revisions Related to Pain Assessment and Management 1 2 Leaders establish priorities for performance improvement. (Refer to the "Performance Improvement"
More informationALABAMA BOARD OF MEDICAL EXAMINERS ADMINISTRATIVE CODE CHAPTER 540-X-10 OFFICE-BASED SURGERY TABLE OF CONTENTS
Medical Examiners Chapter 540-X-10 ALABAMA BOARD OF MEDICAL EXAMINERS ADMINISTRATIVE CODE CHAPTER 540-X-10 OFFICE-BASED SURGERY TABLE OF CONTENTS 540-X-10-.01 Preamble 540-X-10-.02 Definitions - Levels
More informationAPPLIES TO: x SummaCare, Inc. x Apex Health Solutions PRODUCT LINE(S): (Check all that apply)
POLICY NAME: ANESTHESIA PAYMENT POLICY POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 9/25/2017 APPROVED BY: APPLIES TO: x SummaCare, Inc. x Apex Health Solutions PRODUCT LINE(S): (Check all that
More informationWelcome to MGH Gastroenterology Associates!
Welcome to MGH Gastroenterology Associates! Dear Patient, At MGH Gastroenterology Associates our goal is to welcome each patient to our practice and ensure they receive the very best care. Our collaborative
More informationImpact of Medicare COP Changes on HIM
Impact of Medicare COP Changes on HIM Audio Seminar/Webinar March 29, 2007 Practical Tools for Seminar Learning Copyright 2007 American Health Information Management Association. All rights reserved. Disclaimer
More informationAcute. Proposing Surgical Procedure Orders and Orders. Surgical Procedure Orders and Orders Affiliated. Requesting a Surgical Encounter FIN#:
Acute Surgical Procedure Orders and Orders Affiliated Proposing Surgical Procedure Orders and Orders Requesting a Surgical Encounter FIN#: 1. Office calls Pre-registration at 801-387-7646 or 800-624-3972.
More informationThe ASA defines anesthesiology as the practice of medicine dealing with but not limited to:
1570 Midway Pl. Menasha, WI 54952 920-720-1300 Procedure 1205- Anesthesia Lines of Business: All Purpose: This guideline describes Network Health s reimbursement of anesthesia services. Procedure: Anesthesia
More informationThis policy applies to any hospital staff, within KKUH/KAUH, who has privileges to enter data into medical records.
King Khalid K University Hospital King Abdulaziz University Hospital Title: CLINICAL DOCUMENTATION Reviewed by: Date: Department: Unit: Policy Number: HWCPP - 005 Issue Date: DEC 2009 Prepared/Revised
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 02/01/12 REPLACED: 02/01/94 CHAPTER 5: PROFESSIONAL SERVICES SECTION 5.1: COVERED SERVICES PAGE(S) 11
Anesthesia Services Surgical anesthesia services may be provided by anesthesiologists or certified registered nurse anesthetists (CRNAs). Maternity-related anesthesia services may be provided by anesthesiologists,
More informationTACOMA GENERAL/ALLENMORE Rules and Regulations
TACOMA GENERAL/ALLENMORE Rules and Regulations Approval Dates WPRB December th Table of Contents Page Article I Article II Article III Article IV Article V Article VI Article VII Article VIII General.
More informationENVIRONMENT Preoperative evaluation clinic. Preoperative evaluation clinic. Preoperative evaluation clinic. clinic. clinic. Preoperative evaluation
Goals and Objectives, Preoperative Evaluation Clinic Rotation, CA-1 and CA-2 year UCSD DEPARTMENT OF ANESTHESIOLOGY PREOPERATIVE EVALUATION CLINIC ROTATION GOALS AND OBJECTIVES, CA-1 and CA-2 YEAR PATIENT
More informationBenefit Criteria for Outpatient Observation Services to Change for Texas Medicaid
Benefit Criteria for Outpatient Observation Services to Change for Texas Medicaid Information posted on October 8, 2010 Effective for dates of service on or after December 1, 2010, the benefit criteria
More informationNursing Documentation 101
Nursing Documentation 101 Module 5: Applying Knowledge Part I Handout 2014 College of Licensed Practical Nurses of Alberta. All Rights Reserved. Nursing Documentation 101 Module 5: Applying Knowledge Part
More information2012 Medical Staff Update 2011 CHALLENGING STANDARDS/NPSGS
2012 Medical Staff Update Laurel McCourt, M.D. TJC Surveyor: Hospital and Office-Based Surgery Programs, and Special Survey Unit 2011 CHALLENGING STANDARDS/NPSGS 2 Standard/NPSG 2010 Non Compliance 3 2011
More informationPROFESSIONAL STAFF COMMON RULES AND REGULATIONS. Carondelet St. Mary s (CSM), St. Joseph s (CSJ), Holy Cross (CHC), Hospitals TABLE OF CONTENTS
PROFESSIONAL STAFF COMMON RULES AND REGULATIONS Carondelet St. Mary s (CSM), St. Joseph s (CSJ), Holy Cross (CHC), Hospitals The Professional Staffs of all of the (CHN) hospital facilities have adopted
More informationWelcome to MGH Gastroenterology Associates!
Welcome to MGH Gastroenterology Associates! Dear Patient, At MGH Gastroenterology Associates our goal is to welcome each patient to our practice and ensure they receive the very best care. Our collaborative
More informationNURSE PRACTITIONER (NP) CLINICAL PRIVILEGES ORTHOPEDIC SURGERY
Name: Page 1 Initial Appointment (initial privileges) Reappointment (renewal of privileges) All new applicants must meet the following requirements as approved by the governing body effective: / /. Applicant:
More informationCAMH February 2005 Update HIGHLIGHTS
CAMH February 2005 Update HIGHLIGHTS STANDARD UP 1. How to Use Manual Multiple changes to scoring, category changes and Measure of Success (MOS) designation removed 2. Accreditation Policies & Procedures
More informationRULES AND REGULATIONS of THE MEDICAL STAFF of LENOX HILL HOSPITAL NEW YORK
RULES AND REGULATIONS of THE MEDICAL STAFF of LENOX HILL HOSPITAL NEW YORK Table of Contents Article I: General Statement and Introduction...4 Approval of Rules and Regulations...4 Hospital Polices and
More informationUniCare Professional Reimbursement Policy
UniCare Professional Reimbursement Policy Subject: Global Surgery Policy #: UniCare 0012 Adopted: 07/15/2008 Effective: 08/01/2017 Coverage is subject to the terms, conditions, and limitations of an individual
More informationFayette County Memorial Hospital Medical Staff Rules and Regulations 2015
Fayette County Memorial Hospital Medical Staff Rules and Regulations 2015 Section One: GENERAL Rule 1.01 Rule 1.02 These Rules & Regulations adopt and incorporate by reference the definitions contained
More informationCONSENT FOR SURGERY OR SPECIAL PROCEDURES
Admission Date THE VALLEY HOSPITAL CONSENT FOR SURGERY OR SPECIAL PROCEDURES - Colonoscopy 1. Authorization. I hereby authorize Dr. (" my Doctor") and any such assistants or designees as may be selected
More informationEmpire BlueCross BlueShield Professional Commercial Reimbursement Policy
Subject: Global Surgery NY Policy: 0012 Effective: 10/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below.
More informationAccreditation: How to improve efficiency and quality in the hospital
Global GS1 Healthcare Conference Geneva, Switzerland, 22-24 june 2010 Accreditation: How to improve efficiency and quality in the hospital Carlo Ramponi, MD, MBA, Managing Director JCI Europe Ferney-Voltaire,
More informationRules and Regulations St. Johns Hospital Medical Staff
Rules and Regulations St. Johns Hospital Medical Staff Approved by MEC: 06/02/2014 Approved by Hospital Board 06/04/2014 MEDICAL STAFF RULES AND REGULATIONS TABLE OF CONTENTS A. ADMISSION AND DISCHARGE
More informationMA/Office Staff: Proposing Surgical Procedure Orders and PowerPlans (Order Sets)
Acute Surgical Procedure Orders and PowerPlans Affiliated MA/Office Staff: Proposing Surgical Procedure Orders and PowerPlans (Order Sets) This document walks you through: 1. Requesting a FIN (Financial
More informationNOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section.
TITLE PROCEDURAL SEDATION SCOPE Provincial APPROVAL AUTHORITY Clinical Operations Executive Committee SPONSOR Health Professions Strategy & Practice PARENT DOCUMENT TITLE, TYPE AND NUMBER Not applicable
More informationSurgical Technology Patient Care Skills Preop Routine Objectives:
Surgical Technology 8-Jul-09 Patient Care Skills Preop Routine Objectives: 1) Discuss why preop preparation of the patient is important a) Preparing the patient decreases impact and potential risks of
More informationPatient Care Policy. Title: Moderate/Procedural Sedation and Analgesia. Section: Treatment and Tests
St. Joseph s / Candler Health System Patient Care Policy Title: Moderate/Procedural Sedation and Analgesia Section: Treatment and Tests Policy Number: 6061-PC Key Function: TX Effective Date: 05/13/2011
More informationCRAIG HOSPITAL POLICY/PROCEDURE
CRAIG HOSPITAL POLICY/PROCEDURE Approved: P&T, MEC, NPC, P&P 03/09 Effective Date: 02/95 P&T, MEC, P&P 08/09; P&P 08/10; P&T, MEC 10/10, P&T, P&P 12/10 ; MEC 01/11; P&T, MEC 02/11, 04/11 ; P&T, P&P 12/11
More informationAnthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy
Subject: Global Surgery IN, KY, MO, OH, WI Policy: 0012 Effective: 01/01/2018 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria
More informationa. 95 guidelines are based on body systems 97 systems based on bullet points.
Interview questions for freshers Medical Coding Interview Questions 1) What is the basic difference between 95 and 97 guidelines? a. 95 guidelines are based on body systems 97 systems based on bullet points.
More informationStatement on Safe Use of Propofol (Approved by ASA House of Delegates on October 27, 2004);
CREDENTIALING GUIDELINES FOR PRACTITIONERS WHO ARE NOT ANESTHESIA PROFESSIONALS TO ADMINISTER ANESTHETIC DRUGS TO ESTABLISH A LEVEL OF MODERATE SEDATION (Approved by the House of Delegates on October 25,
More informationEligibility Introduction Practice Ethics and Patient Rights and Responsibilities (RI)... 6
Table of Contents Eligibility... 2 Introduction... 3 Practice Ethics and Patient Rights and Responsibilities (RI)... 6 Provision of Care, Treatment, and Services (PC)... 8 Medication Management (MM)...
More informationPROCEDURAL SEDATION AND ANALGESIA: HOSPITAL-WIDE POLICY
CLINICAL PRACTICE POLICY PAGE: 1 OF 6 PURPOSE: These policies will allow clinicians to provide their patients with the benefits of procedural sedation and analgesia while minimizing the associated risks.
More informationClient Alert. CMS Clarifies Interpretive Guidelines for Hospitals Providing Anesthesia Services
Contact Attorneys Regarding This Matter: Mark A. Guza 404.873.8796 - direct 404.873.8797 - fax mark.guza@agg.com Diana Rusk Cohen 404.873.8108 - direct 404.873.8109 - fax diana.cohen@agg.com Client Alert
More informationSTATEMENT ON GRANTING PRIVILEGES FOR ADMINISTRATION OF MODERATE SEDATION TO PRACTITIONERS WHO ARE NOT ANESTHESIA PROFESSIONALS
NOT ANESTHESIA PROFESSIONALS (Approved by the ASA House of Delegates on October 25, 2005, and amended on October 18, 2006) Outcome Indicators for Office-Based and Ambulatory Surgery (ASA Committee on Ambulatory
More informationAnesthesia Policy REIMBURSEMENT POLICY CMS Reimbursement Policy Oversight Committee. Policy Number. Annual Approval Date. Approved By 2018R0032B
REIMBURSEMENT POLICY CMS-1500 Policy Number 2018R0032B Annual Approval Date Anesthesia Policy 3/14/2018 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
More informationJoint Commission Update National Credentialing Forum
Joint Commission Update National Credentialing Forum San Diego, California March 2, 2017 Paul Ziaya MD Senior Director, Field Operations Accreditation and Certification Operations The Joint Commission
More informationDEACONESS HOSPITAL, INC. Evansville, Indiana DEPARTMENT OF ANESTHESIOLOGY RULES & REGULATIONS
DEACONESS HOSPITAL, INC. Evansville, Indiana DEPARTMENT OF ANESTHESIOLOGY RULES & REGULATIONS I. Department Organization and Direction - The Department of Anesthesiology shall be properly organized, directed
More informationCHEYENNE REGIONAL MEDICAL CENTER AREA: TITLE: TrueConnect Downtime/Recovery Procedure. Page 1 of 1 NUMBER: ADMIN-IM-32 ORIGINATOR: CMIO
ORIGINATOR: CMIO Page 1 of 1 POLICY APPLIES TO: Cheyenne Regional APPROVED BY: CEO: COO: CHRO: CNO: CMIO: REVISION DATE: N/A new policy EFFECTIVE DATE: March 2013 POLICY REVIEW COMMITTEE (PRC) REVIEW DATE:
More informationStony Brook University Hospital Medical Staff Rules and Regulations. March 2009
Stony Brook University Hospital Medical Staff Rules and Regulations March 2009 RULES AND REGULATIONS STONY BROOK UNIVERSITY HOSPITAL STATE UNIVERSITY OF NEW YORK AT STONY BROOK STONY BROOK, NEW YORK TABLE
More informationSARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY
PS1070 SARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY TITLE: ADMISSION/DISCHARGE CRITERIA: POST ANESTHESIA CARE UNITS (PACU) EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: Job Title of
More informationTo outline the criteria and management for the patient receiving moderate sedation (conscious
Section: HRMC Division of Nursing Index: 8620.157b Page: 1 of 6 Issue Date: July 1, 1996 Revised Date: January, 2011 PROTOCOL TITLE: MODERATE SEDATION PURPOSE: sedation) To outline the criteria and management
More informationProctoring and Observation for Credentialed Staff Medical Staff Policy
Proctoring and Observation for Credentialed Staff Medical Staff Policy Approved by MEC 1/19/99 Revised 2/2003 Revised 5/2008 Approved SHMC MEC 2/2013 Approved HFH MEC 2/13 Approved PSHMC and PHFH MEC 3-2015
More informationTopical or local anesthesia: Administration of a drug that produces only a localized response with no systemic effects.
Page 1 of 14 Title: Provision of Anesthesia Services_The Continuum from Local to General Anesthesia Version: 3 Approved: Committee - Med Exec, Section - Anesthesia, Robert Dent (COO/CNO Senior Vice President),
More informationARTICLE XIV DEATH Do Not Resuscitate Policy
ARTICLE XIV DEATH 14.1 Pronouncement of Death Pronouncement of death of a patient in the Hospital is the responsibility of the attending physician or his Physician designee. Such judgment shall not be
More informationNon-Employed Advanced Practice Professionals Nurse Practitioner and Physician Assistants who not employees of the hospital.
Stanford and Clinics Lucile Packard Children s Page 1 of 8 I. PURPOSE The purpose of this policy is to outline educational requirements for all Medical Staff and non-employed Advance Practice Professionals
More informationACCREDITATION STANDARDS FOR
ACCREDITATION STANDARDS FOR ACUTE CARE HOSPITALS TABLE OF CONTENTS GOVERNANCE & LEADERSHIP... 1 GL-1: Establishment of a Governing Body... 1 GL-2: Compliance to Law & Regulation... 1 GL-3: Establishment
More informationINCLUSION CRITERIA. REMINDER: Please ensure all stroke and TIA patients admitted to hospital are designated as "Stroke Service" in Cerner.
ACUTE STROKE CLINICAL PATHWAY The clinical pathway is based on evidence informed practice and is designed to promote timely treatment, enhance quality of care, optimize patient outcomes and support effective
More informationHIPAA and Joint Commission Requirements Compared and Contrasted
HIPAA and Joint Commission Requirements Compared and Contrasted Twelfth National HIPAA Summit April 10, 2006 Fran Carroll Corporate Compliance and Privacy Officer Joint Commission on Accreditation of Healthcare
More informationProvider s Guide to the Elective Cosmetic Surgery Superbill
The DHA Elective Cosmetic Surgery Superbill lists CPT /Procedure codes for all elective cosmetic procedures available in the MHS. The Superbill is completed by you, the provider, and used by MSA staff
More informationMedical College of Georgia Health, Inc. Organization ID: th Street. Augusta, GA
Medical ollege of Georgia Health, Inc. Organization ID: 6656 1120 15 th Street Augusta, GA 30912-7600 Accreditation Activity- Evidence of Standards ompliance 1 Form Due Date: 2/8/2005 HAP Standard E.1.10
More informationROLE OF THE ANESTHETIST IN ORGANIZING AMBULATORY SURGERY. Dr. Paul Vercruysse M.D. Belgium
ROLE OF THE ANESTHETIST IN ORGANIZING AMBULATORY SURGERY Dr. Paul Vercruysse M.D. Belgium DISCLOSURES - Conflicts of interest? I am an anesthesiologist... TRADITIONAL ROLE OF THE ANESTHESIOLOGIST EVOLVING
More informationDesignated Record Set Health Record The health information described below may be maintained in any medium (paper, electronic, digital, etc)
Designated Record Set Health Record The health information described below may be maintained in any medium (paper, electronic, digital, etc) DEFINITION Designated Record Set A group of records (recorded
More informationYour Anesthesiologist, Anesthesia and Pain Control
You can reduce your pain level after surgery by planning ahead. For example, if you know that you are going to be getting up to do your exercises with the therapist, ask for pain control medication in
More informationCAH PREPARATION ON-SITE VISIT
CAH PREPARATION ON-SITE VISIT Illinois Department of Public Health, Center for Rural Health This day is yours and can be flexible to the timetable of hospital staff. An additional visit can also be arranged
More informationInterpretation of The Joint Commission Standards Related to Pain Management. Agenda. The Joint Commission Mission 9/6/2012
Interpretation of The Joint Commission Standards Related to Pain Management ASPMN 22 nd National Conference Baltimore, MD September 13, 2012 Pat Adamski, RN, MS, MBA, FACHE Director, Standards Interpretation
More informationMillikin University Decatur, Illinois. Nursing Internship Application for Summer 2018
Millikin University Decatur, Illinois Nursing Internship Application for Summer 2018 Applicant s Anticipated Graduation Date (Circle Response) December 2018 OR May 2019 * Please complete this application
More informationMedical Documentation/Records OUTPATIENT MEDICAL RECORD
OPERATING PROCEDURE No. 151-35 Florida State Hospital Chattahoochee, Florida November 19, 2008 Medical Documentation/Records OUTPATIENT MEDICAL RECORD 1. Purpose: To maintain an Outpatient Medical Record,
More informationProgramming a Spinal Cord Neurostimulator
Programming a Spinal Cord Neurostimulator August 10, 2017 My surgeon wants to bill 95972 for programming along with placement of a spinal neurostimulator. Isn t the programming inclusive to the surgical
More informationPSI 12 - Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate Opportunity
MAY 2018 A MESSAGE FROM THE SAINT LUKE S CARE CMO Table of Contents PSI 12 - Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate Opportunity 1,2 NEW Order Sets & Documents 3 Saint Luke s Care
More informationSurvey Analysis for Evaluating Risk (SAFER ) Insights July 13, 2017
Survey Analysis for Evaluating Risk (SAFER ) Insights July 13, 2017 Caroline Heskett, MPH The Joint Commission, Accreditation & Certification Operations Project Manager, Business Transformation Objectives
More informationTitle: VERIFICATION OF PROCEDURES TO BE PERFORMED
Approved By: Garren Colvin, EVP/COO Responsible Parties: Alicia Humphrey, Director Outpatient Surgery Tracie Shelton, Director Patient Safety & Accreditation Policy No.: ACLIN-V-01 Originated: 01/01/11
More informationQUALITY NET REPORTING
5/18/15% A webinar series that keeps you in the know Brought to you by Progressive QUALITY NET REPORTING Sarah Martin, MBA, RN, CASC Progressive Huddle May 18, 2015 ASCQR ASC Quality Reporting started
More informationParagon Clinician Hub (PCH) Replaces WebStation for Physicians
Paragon Clinician Hub (PCH) Replaces WebStation for Physicians Patient Overview The overview screen allows you to view Recent vital sign data Recent intake and output data Active and recently ended inpatient
More informationEffective Date. N/A Medicare Indicator Status B Services Reimbursement Policy Anesthesia Modifiers
Payment Policy Title Number Last Approval Date Replaces Cross Reference Anesthesia Guidelines CP.PP.017.v2.9 02/27/18 Original 09/01/00 Effective Date N/A Medicare Indicator Status B Services Reimbursement
More informationMeasure Abbreviation: TOC 02 (MIPS 426)*
Measure Abbreviation: TOC 02 (MIPS 426)* *TOC 02 is built to the specification outlined by the Merit Based Incentive Program (MIPS) 426: Post- Anesthetic Transfer of Care Measure: Procedure Room to a Post
More informationPrinciples In developing these recommendations the Consensus Panel first established the following principles for anesthesia outcomes capture:
Outcomes of Anesthesia: Core Measures The following Core Measures are the consensus recommendations of the Anesthesia Quality Institute (AQI) and the Multicenter Perioperative Outcomes Group (MPOG). They
More informationTeamwork, Communication, O.R. Safety & SSI Reduction
2011 Infection Prevention Leadership Teamwork, Communication, O.R. Safety & SSI Reduction Teamwork, Communication, O.R. Safety & SSI Reduction 2 Presented by: E. Patchen Dellinger, MD, FACS Professor of
More informationAdmission Record IVF/Gynae
Admission Record IVF/Gynae Surgeon: Operation : of Admission: Please state your full name and date of birth - correct Nurse Checklist Yes No Please tell me your full address - correct Consent form signed,
More information