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NUR401 Impact Billing Questions essay assignment
You are a new administrator for the mental health division of the Sleepy Medical Center. In this role, you are responsible for the inpatient mental health facility, which has 200 beds, as well as the outpatient mental health clinic. The inpatient and outpatient services are housed in separate buildings on the same campus. A week prior to your appointment, the mental health facility underwent an audit, conducted by the
RI Department of Mental Health. The audit findings highlighted concerns with information management and health care records.
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Audit Background
The primary purpose of the audit was to review the outpatient visits against posted bills to determine if there had been any discrepancies. During the audit, other issues came to light, which were brought to the attention of the medical center.
The primary findings included the following:
There were no notes written in the records that would indicate attendance at group
meetings. There was, however, a sign-in sheet that was kept by the therapist conducting the group meeting sessions.
Due to the high volume of patients, the therapists would write patient notes once a week. This resulted in a brief summary of all the visits made in one week, rather than individual documentation for each visit.
Additional findings were:
The medical records at the mental health clinic were stored in the individual therapist
desk drawers. The drawers did not have locks and not all of the therapists locked their
offices when stepping away for a few minutes.
The psychiatrist in charge often assigned the therapist working with a particular patient to write the psychiatrist’s notes in the medical record. Additionally, the psychiatrist often did not have the time to review the notes the therapist wrote for him.
Mental health information about a patient was shared with the media shortly after the
patient committed suicide in public.
There were complaints from patients who had requested their medical records but were refused their records. All of these patients were moving to another City, and they were all stable patients who complied with their medications.
Case Analysis
When reviewing this case put yourself in the shoes of the new administrator. Ask yourself:
1) How do the primary findings relate to one another? How do they impact billing?
2) Which additional finding will I address first and why is it a priority? (Choose one)
3) Why are these things happening?
4) How are these issues related to information management and health records?
Recommended outline for the case review
Introduction [1 paragraph]
o Briefly describe your role and the situation as the new administrator
Note: You do not need to describe each detail, but give an overview of the
situation in your own words.
o Describe the findings to be discussed (two primary findings and one additional finding)
o State why you have chosen to focus on these issues (your rationale for making them apriority)
Body [1-2 pages]
o Describe the two primary findings
_ What are the facts?
_ Why are they happening?
_ Why are they an issue of information management and/or health records?
Relate it to billing & reimbursement (primary purpose of the audit)
_ What is the legal and/or ethical problem? Explain if the problem violates a law or if it is just a matter of ethics
o Describe the additional finding
_ What are the facts?
_ Why is it happening?
_ Why is it an information management and/or health records?
_ What is the legal and/or ethical problem? Explain if the problem violates a law or if it is just a matter of ethics
o Impact on the clinic
_ What is the impact on the clinic?
o Recommendations
_ How do you propose to correct the situation?
_ If it is a legal or regulatory matter, what laws will you look at to ensure
compliance and reduce liability?
_ If it is an ethical issue, is there a code of ethics or a set of moral values that will reduce the chance of a moral dilemma from occurring?
Conclusion [1-2 paragraph]
o Restate your perspective on the situation and the issues you highlighted
o State the importance of your recommendations to the survival of the clinic
References [goes on a separate page that does not count towards the page limit]
o A list of at least two credible references in APA style
