How To Use The Kura SystemProvider Misc.Write up a Chart Review as a Provider

Write up a Chart Review as a Provider

  • The Chart Review is a visit type in an encounter overview page
  • The Medical Records are submitted for a Provider's review
  • The Chart Review Notes prove that the patient information has been been reviewed and the next steps in the patient's care
  • In the Kura Portal you will find a K-Phrase template called: ".chartreview" that a provider can utilize as a template based on this HDI document

2. Open a Chart Review Encounter

1. Confirm Encounter type is set to Worker's Comp

2. Visit type should be set as CHART REVIEW

3. Submit by clicking UPDATE TYPE

3. Open the Chart Review Notes

1. Navigate to NOTES

2. Click on CHART REVIEW tab

3. Enter in notes using K-phrase ".chartreview" to add notes

4. Pull up the .chartreview K-Phrase

5. Complete the Chart Review Template

Click FINISH when complete

Reference How to Conduct a Medical Record Review (see Billing Room)

Document the Following Items in the Template

  1. Principal Diagnosis
  2. Identified Reportable Diagnosis
  3. Queries
  4. Areas of concern or needed follow-up
  5. Explanations or comments for any issues or inconsistencies found within the record
  6. Identified date or plans for re-review prior to discharge.

Principal Diagnosis

  1. Where the diagnosis was found in the record-The sequencing rationale, if multiple conditions could be the principal diagnosis—this could include clinical concerns/focus of care,
  2. AHA Coding Clinic® guidance, and
  3. ICD-10-CM Official Guidelines for Coding and Reporting

Identified Reportable Diagnoses

  • Include where the diagnosis was found in the record: “AKI w/ATN; nephrology consult 7/1/18, Dr. Nephro”-
  • Accompanying clinical indicators (labs, diagnostics, assessments) to support the presence and reportability (treatments, medications, etc.) of diagnoses—include sourcing and dates for all information:-“Creatinine rise to 3.5 from baseline 1.6 within 36 hours of CT contrast administration”-Clarification of POA status with clinical support as appropriate:-“Stage 4 pressure ulcer, left hip, POA-Y (nursing admission assessment 6/30/18)”-
  • Flags or indicators for diagnoses providing CC/MCC or HCC, contributing to SOI/ROM, triggering a quality measure, etc. as appropriate to the encounter and purpose of the review:-“AKI with ATN (POA-N)—MCC”-“Stage 4 pressure ulcer (POA-Y)—MCC, HCC”-“CAUTI (POA-N)—HAC

Queries

Include:

  1. Date of query
  2. Supporting clinical indicators
  3. method (verbal and /or written)
  4. physician response
  5. any needed follow up

Example: "7/1/18 Dr. Nephro: Verbal query for ATN related to IV contrast. Physician agreed."

Areas of Concern or Needed Follow-Up

Note: any issues that are to be resolved in a repeat review, examples:

  • "CXR 6/30/18 notes right lower lobe infiltrate, white count trending upward to 10,000.”
  • “Nursing assessment 6/30/18 0300: Patient demonstrating confusion to place and time. Requiring frequent reorientation.”
  • “Blood count demonstrating drop on DOS, EBL 150 cc with large infusion of fluids. Check repeat H&H tomorrow."

Explanations or comments for the coding staff or other team members

Communicate any issues or inconsistencies found within the record, examples:

  • Dr. Smith states the patient’s fluid overload is not related to cardiac function”
  • “Dietitian states high BMI is not related to obesity—patient has dense muscle tissue."

Identified date or plans for re-review prior to discharge

Flag the record for follow up if necessary, examples:

  • "Surgery scheduled 7/1—re-review 7/2”
  • “No need for further review unless patient is not discharged 7/1"

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