Compliance is just one of the primary concerns within your home health and hospice agency. Good compliance starts with strong documentation, which can include anything from patient charts to care notes and in-house patient files. Unfortunately, even the most experienced agencies can run into trouble with costly penalties.
Smart healthcare document management techniques can prevent errors that erode confidence in your business, instead building a strong foundation for success among administrators, clinical managers, and compliance officers.
Here are some things you should know about good documentation, why it matters, and how to use automation to avoid common pitfalls.
Centers for Medicare and Medicaid Services (CMS) and the Health Information Portability and Accountability Act (HIPAA) audits depend on clear, consistent documentation. Missing details and incomplete records can quickly turn into violations. For example, inconsistencies or outdated forms can prompt questions during audits and, in some cases, fines. Poor home health documentation compliance can result in penalties, including denied claims, fines, and reputational damage.
Signatures are a necessity when it comes to patient care plans. If an auditor discovers that care plans have been missed and no signature is present, then those documents could lead to you failing your audit. Fortunately, e-signatures and automated reminders prevent oversight and can help you avoid the penalties that poor compliance could cause.
Different staff inputting variations in names, dates, or codes can trigger inconsistencies that draw concern during audits. The solution is automated data syncing. Automated data syncing keeps records uniform, preventing issues linked to inconsistencies.
Paper charts and shared drives create error risks, since there is no single source of truth that all people can turn to for information. Enterprise content management keeps everything centralized in one place, making it easier to demonstrate audit readiness when inspectors turn up at your door.
Entering care notes days later is not compliant. Delaying updates can raise questions about patient care and may also produce errors. With automation and the right tools, it’s possible to perform real-time entry and auto-sync updates to maintain accuracy. For example, Mobile Complete allows you to complete documentation wherever you are from your mobile device. This tool allows healthcare professionals to deliver rapid results and updates without delay.
Agencies are unknowingly using last year’s CMS forms, which can end up causing serious compliance concerns. Using outdated forms or failing to notice template changes can give rise to unnecessary, duplicated work and potential audit problems. With automated version control, you’ll only work with the latest templates, helping to protect your team while meeting state and federal requirements as they evolve.
Overly broad access to patient files and documentation creates HIPAA exposure, which puts your patients’ information at risk. HIPAA compliance concerns can quickly lead to trouble for your agency, too, whether that is through concerns from auditors or patients themselves. One solution is to use role-based permissions to secure sensitive data. With role-based permissions, only those who should be looking at specific patient files or information have permission to do so, and others are restricted. This process limits the release of information to those who do not need to see it and protects the patient’s personal information from being exposed unnecessarily.
Being unprepared for audits causes a push for more work to get done in a last-minute panic. That panic can result in errors that could otherwise have been avoided. Manual audit preparation is time-intensive and stressful; automated audit trails help by ensuring you’re always ready for an audit. These compliance automation tools track every update, signature, and approval, allowing for consistent audit readiness and a reduction in last-minute pressure to prepare.
Correcting documentation mistakes after they’re made takes time, and it can be costly if you don’t spot them until after an audit. Preventing mistakes and errors is much easier, but only if you step away from manually inputting every piece of information that you collect. Automation is the path to consistent compliance. It transforms your compliance efforts from stressful, time-consuming processes to a steady, reliable routine that keeps you on track every day.
With strong healthcare documentation management techniques and tools in place, your agency will be better positioned to protect itself against audits and potential penalties. You’ll also be better positioned to provide high-quality care to your patients and maintain confidence that you are doing everything by the book.
Automation can make the difference for your team. Learn how WorldView supports compliance success.