EMRs for Long Term Care

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Joleen Henderson
8 years ago
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1 A Simple Checklist EMRs for Long Term Care Consider these 7 signs that your facility is overdue for an Electronic Medical Record system

2 Do you need an EMR? Your need for an EMR is not unique, and thousands of nursing homes have resolved documentation issues by replacing paper records with an Electronic Medical Record System. Ask yourself these questions Did your last survey result in deficiencies that you need to resolve quickly? Did your paper documentation fail to confirm that your residents receive good care? Did your paper documentation provide enough information to support your residents MDS 3.0 records and billing claims? Keep reading to learn about 7 issues that can be resolved by an EMR. You might be overdue for one!

Medical Record System. Ask yourself these questions Did your last survey result in deficiencies that you need to resolve quickly?

3 ONE Admission details are recorded in several places and do not match. Problem: The Admissions, Social Services and Billing departments ask new residents and their families many of the same questions. They record the answers on their own forms, which might not be shared. This lengthens the admission process and frustrates your new residents, who feel they are not being heard. Solution: With an EMR, all departments access, update and share a centralized Resident Face Sheet record. Demographic information recorded in the Face Sheet automatically populates other areas of the resident s chart, ensuring consistency and accuracy and reducing duplication of effort.

They record the answers on their own forms, which might not be shared.

4 TWO ICD diagnosis codes on Face Sheets and MDS records do not match the codes on billing claims. Problem: Billing with an ICD code that isn t supported by the MDS record can result in denied claims and billing audits, which are costly and time-consuming. Solution: With an EMR, the nursing and billing staff maintain diagnoses in the same area of the electronic Face Sheet. These codes populate the MDS and the bill. Both are submitted with current and accurate diagnoses.

audits, which are costly and time-consuming.

5 THREE Flow Sheets don t accurately capture the care provided. Problem: Paper Flow Sheets offer many opportunities for error. Missing observations, copying previous answers forward and using inappropriate responses all contribute to inaccurate ADL and RUG scores that could result in reduced reimbursement. Solution: With an EMR, after providing assistance, the care-giver goes immediately to a wall-mounted kiosk or tablet PC and records the assistance into the ADL tracking module. The EMR tabulates these entries, calculates the MDS responses and puts them into the MDS record. The EMR determines the ADL based on the correct information, ensuring accurate reimbursement and documentation that supports the MDS.

6 FOUR Late submission of MDS records results in default rate payments. Problem: It is a challenge to keep track of the various types of MDS records to be completed, and so easy to miss one. This results in payment at the default rate and loss of valuable reimbursement dollars. Solution: An EMR creates each resident s MDS 3.0 schedule based on payment type, admission and readmission dates, and current MDS 3.0 ARDs. You receive daily and weekly alerts for the MDS records that are due. For Medicare residents who receive therapy, the alerts tell you if a COT is due, early or late, and if a COT should be combined with a scheduled MDS.

This results in payment at the default rate and loss of valuable reimbursement dollars. Solution: An EMR creates each resident s MDS 3.

7 FIVE Paper MARs allow for late administration and med errors. Problem: With paper MARs, meds are sometimes missed or given late. Vitals are not always recorded for meds that require them. Outcomes are not always recorded for PRNs. Your staff must remain constantly vigilant to maintain resident safety. Solution: An Electronic Medication Administration Record (EMAR) alerts you when meds are due and warns you if meds are late or not administered. Bar code scanning confirms that you are about to administer the right med to the right resident at the right time. An electronic system requires that all vitals readings and outcomes are recorded.

Your staff must remain constantly vigilant to maintain resident safety.

8 SIX Paper records require more storage space than you have. Problem: Paper charts are big and bulky and require shelves of storage space. When a chart becomes too full to manage, you must archive older records in another area. Solution: An EMR provides all the storage space you need in a searchable electronic filing system that can be shared among staff members. You can scan images of original documents so that they are readily available on-screen. You can e-sign records and keep electronic copies rather than printing them.

When a chart becomes too full to manage, you must archive older records in another area.

9 SEVEN Sorting through and analyzing paper records seems impossible. Problem: It takes hours to document residents conditions and the care provided. Yet, it s not easy to gather and organize the information to learn... o What was the fall rate last month? o Who still needs a flu shot? o Who attended Bingo yesterday? o Which residents should be seen by the physician? Solution: An EMR allows easy access to a massive collection of medical data. Design your own reports and select from pre-designed reports, such as: o CMS-672 Resident Census o CMS-872 Resident Roster o QA for Care Plans o Medications by therapeutic class

o Who attended Bingo yesterday? o Which residents should be seen by the physician?

10 Electronic records provide mobility that allows you to easily share information and interact with your staff and residents in a more meaningful way. And that is how change happens. One gesture. One person. One moment at a time. - Libba Bray

11 Let Hi-Tech Software help you transition to an EMR. With 30 years of experience in long term care software, our proven conversion process, skilled trainers and expert support staff are with you every step of the way! or Call Lynne: (207)

conversion process, skilled trainers and expert support staff are

Moving your Facility to an Electronic Medical Record

Moving your Facility to an Electronic Medical Record 1 Table of Contents Paper vs Electronic The Pros and Cons Page 3 Considerations As You Move Ahead Page 10 Infrastructure Page 14 Your Current Software