Medicare: "Hospital-Acquired Conditions" and "Present on Admission"

Here is how the whole reporting of hospital-acquired conditions began: the hospital billing form was changed to include fields for present-on-admission indicators for EVERY SINGLE coded diagnosis for EVERY patient, whether they're Medicare, Blue Cross, whoever. The indicator choices are "Y-yes", "N--no", "U-unable to determine" or "W-not enough information to determine".

Beginning 10/1/07 this information has been going out to everyone: Medicare, commercial carriers, public aid, whoever. Once it is "out there" hospitals no longer have control over who sees it. Patient names may be protected, but the hospital-acquired condition (HAC) info isn't.

Many websites (HealthGrades, LeapFrog, Hospitalcompare) are using this information to provide information to the public about hospital performand.

Who controls what gets reported? The physicians. Only physician documentation is allowable for the reporting of ANY diagnoses. The information (positive urine cultures, etc) may be in the record but coders are not allowed to code from anything but physician documentation; this means the doctor must state the diagnosis in his dication, progress notes or orders first.

So: if the doc doesn't document the UTI/MRSA whatever until the 4th or 5th day of the stay the coder will code that diagnosis as "not present on admission".

Look at the situation another way: if you brought your car in to have the oil changed and drove away and your car failed due to the service station accidentally forgetting to replace the oil or, perhaps, draining your transmission fluid, wouldn't you expect the service station to pay for the repairs? Of course you would. Would you accept their excuse "well, it was an old car anyway". Of course not.

I review thousands of inpatient records every year with the specific goal of analyzing the physician documentation (and sometimes nursing documentation) to ensure that every condition that is treated, monitored or evaluated is documented. This is what constitutes a compliant record of the patient's care.

I've seen a disturbing trend of less and less documentation of what we're doing for our patients. There's less documentation that critical conditions were monitored, less documentation that sterile technique was used, and probably the biggest infection issue is that more and more is delegated to unlicensed personnel who have less than optimal infection-control techniques. Procedures that were previously done by nurses who used careful sterile technique are now delegated to aides who only have to have 6 week's training and from what I've seen, easily influenced by others' bad habits.

The fact is, we ARE causing these problems. But now everyone will know we are and this is forcing hospitals to take action and preventative measures. The result will be better patient care. People are being forced to be more careful, document more specifically and to be aware of the risk factors that cause these incidents. I don't see this as a bad thing. The maxim "if you didn't document it you didn't do it" is still true today.

Which of the nurses out there doesn't dread having to be a patient in a hospital today? I know that I do and if I was I'd want a nurse friend at my bedside 24 hours a day to make sure that I received the proper care.

Medicare already has a system in place to monitor, heart failure and Pneumonia, and surgical measures, adding more won't be new to them.

Just FYI, in some countries you can buy antibiotics at a pharmacy without a prescription. Also, when I lived abroad in another country, many patients wouldn't feel that they got their money's worth for the appointment if the MD didn't give them some kind of medicine; the MDs, competing for patients, catered to that customer demand by dispensing antibiotics even when they probably wouldn't make a difference... so US isn't "the only system" that overuses antibiotics to satisfy "customer demands". It doesn't make it right, but it's not uncommon either.