Case Management

Case management Q&A

Case Management Weekly, May 30, 2012

Q. What documentation is necessary at the time of inpatient admission?

 A. Answering the following questions will help ensure necessary information is documented at the time of inpatient admission:
  • What services the patient was receiving before admission?
  • Were the services medically necessary or custodial in nature?
  • Did lack of medically necessary services contribute to the reason for admission?
  • Does documentation show what is known about the patient’s point of origin for inpatient admission (e.g., ED, home, outpatient setting, skilled nursing facility, freestanding clinic)?
 This week’s tip is adapted from Discharge Planning Guide: Tools for Compliance, Third Edition, published by HCPro, Inc.

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