Sarah Reed presented on the feasibility of moving Drake Center's medical documentation to an electronic system. Currently, paper records are used but regulations from CMS require improvements to documentation. Electronic records could help by decreasing paperwork, increasing productivity and staff satisfaction compared to paper records. Sarah chose this topic because as a child of a nurse, she witnessed how outdated documentation systems led to errors and how moving to electronic records could help hospitals modernize and improve quality of care.
2. Introduction The feasibility study is to determine the feasibility of placing documentation into an electronic regulated medical record system at Drake Center
3. Background Centers for Medicare and Medicaid Services (CMS) develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to be Medicare and Medicaid certified, which is required in order for the facility to be paid for providing the care. These minimum health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.
4. Background (continued) The patient’s medical record is used to document the assessment of the patient’s condition, to justify treatment or continued hospitalization, to support or revise the patient’s diagnosis, to support or revise the plan of care, to describe the patient’s progress and to describe the patient’s response to medications, treatments, services and provide appropriate care as well as document the quality of that care.
5. Topic Problem: Medicare and Medicaid Services place new regulations for documentation, which cause more paperwork to be done. These create 3 negative effects: Decrease in productivity Decrease in staff satisfaction Lots of paper work
6. Topic (continued) Why I choose the topic: I have been around hospitals all my life since my mother is a nurse. Being around hospitals I have seen many problems due to hospitals having trouble moving its technology into the 21st century. This has exposed errors in hospital’s documentation systems. Even though becoming a nurse is something I do not want to do, it does however interest me since this does affect my mother.
