Myrtle Hilliard Davis Comprehensive Health Centers, Inc.
Timeliness of Documentation
Policy: Timeliness of Clinical Advice DocumentationDuring Hours of Operation, After Hoursand by Secure Electronic Communications. (PCMH1B)
Department: Medical
Approved by: President/CEO
CMOE
Effective date:
Purpose: To assure patients receive response in a timely during work hours, non-traditional hours, through electronic communication i.e. instant messaging, texting or patient portal. The timeliness of response is determined by the type of message and the time during which the communications are received. The documentation of clinical advice is critical to the process of patient continuity and maintaining record of these contacts for evaluation of effectivenessand patient compliance.
Policy: The provider staff or his designee will respond to all communications in an appropriately defined time frame. The time frames will we delineated by the time of day communication is received. To better delineate the times the providers will use the following process in sending responses.
Category 1: During business hour Monday thru Friday 8:00 a.m.-5:00p.m., providers will use (encounter code 207) to document phone calls, instant messaging or patient portal communication must be answer by the end of the work day. Telephone calls, instant messaging of patients concerns will be prioritized by the licensed personnel working with the providers.
Category 2: Providers will use (encounter code 206) to document after hour communications with patients must be returned according to the After Hours of Operations Medical/Dental Coverage Policy. Phone calls response will occur within 15 minutes. The electronic communication response should occur within (30-60)minutes.
Category3: Providers will use (encounter code 208) to document electronic messaging documentation during and after hours when corresponding with patients through secure electronic communication devices, i.e. e-mail, text messaging/instant messaging or patient portal. The electronic communication response should occur within (30-60) minutes.
All communications will be monitored by the PI committee for compliance with practice established guidelines. The measure used will be the encounter code used to document patient clinical advice during hours, encounter code used after hours, encounter code used for electronic communications.
This measure will evaluate compliance of practice with timely clinical response: documentation must within one-month period.
Numerator = Number of patients receiving clinical advice (during hours, after hour, and electronic communications.
Denominator = Number of patients in the patient universe with clinical advise documented in the medical record.
Documentation in the electronic health record must be completed with 24 hours. The documentation is a critical factor in maintaining continuity of care. The documentation must include the following information: The Provider must document: Date, time, chief complaint, medical advice, prescriptions transmitted and signature of person completing correspondence and documentation.
The provider designee must document permission from provider to give instructions and include: Date, time, chief complaint, provider directed medical advice, prescriptions transmitted and signature of person completing correspondence and documentation. All documentation by provider designee will be through the tasking function in the electronic health record.
Method and Data source: will be retrieved from EHR patient universe, Call logs from the exchange for after hours, encounter codes for after hours, encounter codes for electronic communication and documentation entries the record/tasks communicated between provider and team.
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