In this module, you learned how tools and technology can help with the documentation process. They make regulatory compliance and audits easier for healthcare organizations.
This activity will help you assess how technology supports regulatory compliance in healthcare. It also enables you to explain how electronic documentation systems support billing and payment reimbursement.
You are the manager of the coding department for a healthcare organization and have found a coding error while doing a preliminary compliance audit of claims submission to Medicare. You found that the physician has entered incorrect procedure codes on encounter forms and found similar errors on other supporting documentation, such as patient visit summaries, electronic medical records, etc., for the last quarter. You also notice that the documentation and coding policies and procedures have not been updated in three years. You need to examine the situation and recommend actions to mitigate the error.
Create a situation, background, assessment, recommendation (SBAR) analysis using the template provided to assess the documentation and coding scenario and recommend ways to rectify the situation. Explain the situation in detail, followed by background information. Include any assumptions you are making about the situation. Then explain the immediate assessment and recommendations you have for your supervisor.
You may want to review the resources in this module to refresh your knowledge of how to create an SBAR analysis. If you need writing support, access the Online Writing Center through the Academic Support module of your course.
Specifically, you must address the following rubric criteria:
All the claims in your deliverable should be evidence based. Your citations should be from your independent search for evidence (not from the textbook or module resources) of credible sources and be current within the last five years. You are required to cite a minimum of two sources. Refer to the IHP 630 Library Guide located in the Start Here section of the course for additional support.
What to Submit
Submit your completed SBAR Analysis template as a 1- to 2-page Microsoft Word document with double spacing, 12-point Times New Roman font, and one-inch margins. Sources should be cited according to APA style