Improving anesthesia documentation compliance through integr | 56487



Improving anesthesia documentation compliance through integration of alert systems and electronic health records

Cindy B. Yeoh

The eligibility requirements to guarantee payor reimbursements for anesthesia services is becoming increasingly stringent. Institutions must comply with documentation standards set by the Center for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC).Such documentations often involve recordings of clinical events at specific times and attestations affirming that a particular assessment or procedure is performed. Alert systems have been implemented throughout numerous industries to reduce mistakes and enhance efficiency through improved quality control. In healthcare, alerts are sent by clinical decision support (CDS) systems integrated with electronic medical records (EMR) to assist healthcare providers, either by a passive alert system or an active system with real-time guidance. By analyzing clinical data and deviations from hospital standards in the EMR, CDS systems can potentially improve the quality of patient care, reimbursements, and compliance with regulatory requirements.