Uniform Hospital Discharge Data Analysis

UHDDS – Uniform Hospital Discharge Data Set collects data elements from only inpatient health records.

Appointment/Registration - This determines whether an individual is an established or new patient; if the patient is new, then insurance information is obtained and verified to make sure that the patient qualifies to receive services from the provider.

The first area outlined in the intake form is the client’s demographic information that included the client’s date of birth, social, insurance information, etc. necessary to process claims for reimbursement and the client’s provider information, such as primary care, and case management, to ensure fluidity for establishment of coordination of care between providers. The intake form

Improve the accuracy of patient identification. The recommendation is for all healthcare providers to institute a policy of using at least two patient identifiers when providing care, treatment, and services. This goal has two objectives, one to verify the individual as the person for whom the service or treatment for and to match the service or treatment to that individual.

In addition, it also measures the quality of care and patient satisfaction. In 2015, the US Secretary of HHS has announced a goal of 85 percentages of Medicare Fee for Service payments tied to quality or value. In addition, many new payment models are associated with HRRP; for instance, forthcoming Skilled Nursing Facility VBP program and Dialysis Adequacy measure , potentially specifies preventable readmission measures. As the system is moving from quantity to quality, it is beneficial to implement quality of standards to optimize future benefits for the community and Central Health as well. Currently, Central Health has higher readmission rate than national average with an overall rating of 2 out of 5. Penalties incurred due to below standard of care could strain hospital resources to utilize for the betterment of our facility. Furthermore, the incentive structure has concerned Central Health to reevaluate the mode of practice and care provided engaging healthcare providers and patients. Central Health is committed to reducing readmission rates by identifying and sharing best practices for long term benefits. Given the flexibility of penalty under the 21st Cure Act, the initial program will focus on readmission prevention within 30 days of hospital

In 2003, The Joint Commission made one of their first goals to improve the accuracy of identifying patients to reduce or eliminate patient identification errors. This continues to be an accreditation requirement. Their recommendations to do this are to use at least two patient identifiers when administering medications, and when providing treatments or procedures. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier. Patient room number or physical location may not be used as an appropriate identifier. Healthcare provides should re-identify the patient with each encounter, each medication pass, and each procedure. There have been procedures and protocols throughout the country have been put into place to make the care provided to patients safer. Another element of this requirement is that all containers should be labeled in the patients presences after using the patient identifiers

Locator 17-17a-b: Name of the referred physician or another source; I.D number of referred physician; NPI number

Lastly, a current and new survey that is used as a surveillance method is the National Hospital Care Survey (NHCS). The NHCS integrates inpatient data previously collected by the NHDS with the emergency department, outpatient department, and ambulatory surgery center data collected by the NHAMCS. The integration of these two surveys along with the collection of personal identifiers such as protected health information will allow the linking of care provided to the same patient in the different facilities they may have visited as an outpatient or inpatient. “It will also be possible to link the survey data to the National Death Index and Medicaid and Medicare data to obtain a more complete picture of patient care” (CDC,2017).

According to Weber & Kelley (2014) the biographical data information, such as name, address, age, date of birth and gender could help identify the person. In addition, the patient’s martial status, nationality and religion could help nurses to examine the person’s belief or special needs that may affect the healthcare treatments. Furthermore, the information of the person’s occupation can help identify their possible strengths and limitations that could affect their health status as some works might be a cause of overwhelming stress, which would have an influence on his or her health.

The Centers for Medicare & Medicaid Services (CMS) was made headlines by releasing charge and Inpatient Prospective Payment System (IPPS) installment data at the MS-DRG level for hospitals across the country. In spite of the fact that this data has long been openly accessible, having it provided more easily available brought about it by being reported of various media outlets. Tragically, this information discharge was not accompanied by expert information clarifying what the numbers mean, creating an interest for hospital facilities to react, at the end of the day, to forceful request in regards to their charging practices.

Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. For diagnostic coding in medical practices, defined as the main reason for the patient’s encounter with the provider. Diagnosis codes are generally used as a representation of admitted episodes in health care settings. A number of diagnostic coding systems are currently implemented across the world to code the stay of patients within a typical health setting such as a hospital. Under the hospital inpatient rules, the principal diagnosis is listed first. This principal

Documentation that would fall under (“S”) or subjective items are symptoms or things you can not see, such as pain. Under the (“O”) you would place symptoms or items that you can clearly visualize. Any assessments, evaluations, or findings should be documented under the (“A”). Finally, the (“P”) is where any plan of action or intervention should be documented. This is where you would typically find informed consents along with any attention care plans to alleviate any health issues. Additionally, if a patient any initial treatment or medication, the results of such treatment should be put here. (“G”) is often added to the end of SOAP, which is a place designated to document any goals or expectations the healthcare professional may have for the patient. A variation of the SOAP format is problem-status-plan (PSP), which is used for patient progress and revision notes. Listed under (“P”) problems, are the patient’s previous diagnosis and or prior evaluative findings. Under (“S”) status, you will place the patients subjective information along with the objective findings. Lastly, under the second section labeled (“P”) plan, the revised plan of care for the patient.

The hospital has 320 inpatient beds with capacity of 80 beds in an emergency department. It employs 600 nurses and 45 staff physicians and 40 residents. The hospital system uses an EHR that supports all clinical activities. The proposed intervention is to develop and implement the enhanced discharge summary template within an EHR system that integrates prompts and automatically populated core components of a quality discharge summary (Smith et al, 2017).2 With inpatient physicians, outpatient physicians, nurses, patients, and families as customers in mind, few changes made in the pre-intervention template are: a) an addition of a section for follow-up care needs like tests, pending labs, and provider responsible for follow-up care b) an insertion of subheadings and menus that addressed crucial elements of patient’s condition like cognitive status, activity level at discharge, and indwelling lines and catheters. c) an accommodation of advanced care planning d) an elimination of a list of diagnosis as stand-alone component and assimilation as part of the problem-based hospital course (Smith et al,

In my opinion, discharging patients from the hospital is a complex process that is fraught with challenges. In this case, 55 years old man is a senior citizen and suffering from a severe disease he should not be discharged for a measurable time limit because it has been observed in the USA that around 20 percent of patients are readmitted within one month after their discharge from hospitals. As the matter of the payment of medical expenses of the old man is concerned, there are always arrangements on behalf of the government in all states of USA.With efforts to decrease the length of stay for hospitalized patients over the past two decades, a reasonable concern has been raised that early discharge, if premature, could increase rates of readmission.

Ambulatory services consist of an array of healthcare services offered to inpatients overnight at healthcare organizations. Funding of ambulatory services should be done at urgent care, outpatient clinics, same day surgery, group practices, mental health clinics, community health care units, diagnostic centers, and emergency rooms. In order for ambulatory services to grow, they must be funded tremendously. Its funding must be based on the desire for the government and insurers to control the cost of healthcare (United States, 2005). Additionally, funding should focus on advanced technology, which makes many surgeries and tests were previously conducted at hospital settings, safe to be conducted at freestanding centers and clinics. Expensive specialty equipments should be developed to establish centers for carrying out diagnostic tests in healthcare organizations.