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Home This Month E-Weekly Newsletter Building a Facility Article Archive Second Opinions
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Outpatient Surgery E-Weekly

Malpractice Verdicts Often Favor Physicians

Physicians come out on the winning end of 80% of malpractice claims that end in jury verdicts, according to researchers at Massachusetts General Hos...

Study: CT Colongraphy Effective in Finding Polyps

A CT-scan-based, laxative-free "virtual colonoscopy" may be as effective as standard colonoscopy in finding potentially cancerous polyps, according ...

Wrong-Site Prevention Video Shows the Right Way

Wrong-site, wrong-patient and wrong-procedure surgery must be prevented at all costs. The 3 steps of the Joint Commission's Universal Protocol make ...

Archive > August, 2011 Vol. XII, No. 8

Compliance Corner

Show Me the Documentation

Debra Stinchcomb, RN, BSN, CASC

Medicare surveyors and accreditation inspectors follow a simple code when they step inside an ambulatory surgical center: If it's not documented, it didn't happen. Documentation is important not only to remain in regulatory compliance, but also to demonstrate your facility's attention to quality and safety. Here are 8 types of documents that ASCs sometimes overlook.

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Administration; Annual; Contact; Determine; Document; Documentation; H&P; HIPAA Privacy Rule; Health Administration; Human; Intraoperative; It's; LSC; MEC; Medicare; Meeting; ORs; OSHA; Occupational Safety; Physical; Privacy Rule; QAPI; RN; Regular; Reviews; Rule; Safety; Surgical; Surveyors; Update; abuse; accreditation; accurately; action; actions; activities; adherence; administered; ambulatory; ancillary; annually; approval; approve; areas; assess; assessment; assurance; attention; aware; benchmarking; blue; board; body; break; bylaws; called; care; challenges; clinical; code; committee; company; competencies; compliance; comprehensive; conducted; consistent; contract; control; customized; date; day; delegations; delineation; demonstrate; denote; details; didn't; disaster; discharge; discuss; doctor's; document; documentation; documented; documents; drills; emergency; ensure; environment; equipment; evaluated; executive; facility; facility's; files; find; fire; flash; follow; frames; governing; history; housekeeping; humidity; important; improvement; in-service; include; indicating; infection; initial; inside; inspectors; internal; it's; items; job-based; knocking; laser; life; list; local; make; malignant; management; managers”; match; medical; medication; members; minutes; missing; mock; monitor; needed; note; office; officer; open; operating; opportunities; order; ordered; orders; pain; paperwork; parameters; part; patients; performance; performed; personal; personnel; physical; physician; place; policies; policy; pose; post-op; prior; privacy; privilege; procedure; processing; program; programs; proof; protective; provide; providers; providing; quality; ready; receive; recent; recommends; records; reflect; refrigerator; regular; regulatory; relate; remain; require; requirement; requires; resources; response; reviews; revised; role; safety; separate; service; show; sign; signed; simple; small; staff; state; step; sterile; sterilization; surgical; surveyors; temperature; term; time; training; trend; types; update; written; you'll; you're; —; “big”; “board

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