Severity of Illness - Essay Example

Introduction

The medical documentation entails the record of health and the charts used to enter information about a patient medical history in the health center. It ensures the provision of quality care to the patients by providing accurate data information on the number of visits to the center and indicating the services provided. The severity of the illness shows the extent or degree on which a specific ailment has caused the body's organ. The severity of the condition is used to display and evaluate the impact of disease and all the available resources to provide care guidelines by the hospital. The severity of a disease can be in different stages, including minor, moderate, significant, and extreme levels of the severity and how the patient is safe or in the risk of mortality.

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Hospital-acquired conditions can be described as the unwanted condition that a patient is likely to develop while inside the hospital being treated (Kok et al., 2018). Hospital-acquired infections can be high and too risky for patients' health if not well treated. Present on admission indicators entails the current time conditions when order occurs for admission of a new patient. Helps to determine the urgency needed for the patient and references on changes in improvement. The case-mix shows the number of patients attending a similar test and grouping them according to the illness's characteristics.

Present on Admission

Based on the Present on Admission (POA), the patient will be examined on arrival before order and admission to determine the current condition. It helps the hospital to avoid paying extra charges of treating the avoidable complications of inpatient. An example is if a patient is tested to have malaria while admitted. In the case of contradicting another disease while in the hospital premises, the hospital will not be liable when filling billing Medicare. The case-mix will be used to measure and access all the resources a patient needs to be treated in the hospital. It is calculated to show the complexity and intensive caseload of the hospital to the patient. A high case-mix will lead to more reimbursement dollars since it will show that the hospital is dealing with sicker patient size.

Revenue and reimbursement can be affected by understanding the claims in the context of the revenue cycle. Also, the claim process's critical stakeholders should be identified, which will involve skilled personnel to monitor the whole process. Further, information about policies on reimbursement strategies should be taught to the management. The physicians should be educated and trained through documentation sessions to improve the standards. They should use evidence-based reasoning when preparing to be aware of real-life situations and provide performance monitoring support that will be used to show each physician's progress. The documentation should be accurate on medical information, easy to access the record, and should be updated often when needed.

Conclusion

To educate on the coders, the hospital should educate on how to ensure that the patients’ data is logged in accurately in the electronic health record by the physicians. They should learn how to keep a track on the patient details while in the hospital and ensure that the documentation process should entails every task performed. It helps to analyze all steps involved and provide final copy on the patients’ information.

Reference

Kok, M., van der Werff, G. F., Geerling, J. I., Ruivenkamp, J., Groothoff, W., van der Velden, A. W., ... & de Graeff, P. (2018). Feasibility of hospital-initiated non-facilitator-assisted advance care planning documentation for patients with palliative care needs. BMC palliative care, 17(1), 1-8.