Q: What has been the challenge in documentation according to standards set by the Accreditation Association of Ambulatory Health Care?
John Lytle: There have been some changes last year in the CMS standards and how information is documented. For example, ASCs have always had to make sure certain pieces of information were put into patients’ charts in a timely manner, such as confirmation of giving patient rights.
Patients now have to be given their rights prior to the date of service, such as an explanation of their grievance rights, HIPAA rights, information as to who owns the facility and so on. Other examples of patient rights are advanced directives or living wills. Now, all these things have to be discussed before the date of service. We also have to turn around and prove to the state that the discussion took place.
Making sure patients were explained their rights prior to the procedure was the big challenge for us. We don’t see patients prior to procedures. We’re a facility where you walk in the day of the procedure, and we usually don’t see them or have any contact with them prior to that date of service.
Q: What new processes had to be implemented in order to better meet those standards?
JL: We use electronic documentation here, and there are checks and balances in the system to make sure those pieces of information are being captured correctly. Electronic records have helped us record the process of giving patients their rights and proving that we did it. Physicians’ offices also coordinate with us to make sure phone calls were made and information about their rights was mailed out. After explaining or reviewing their rights, we have each patient sign off on a consent form acknowledging that they received these rights.
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