Hierarchical condition categories program

Abstract

Systems and methods of recording patient's medical documents and training programs for improving medical document recordation. The system includes a computer readable medium capable of storing medical data obtained from patients, including disease codes, a computer with software capable of evaluating the data stored on the computer readable medium for completeness, and a notification system capable of presenting to the user of the system a warning if any of the data is found to be incomplete or incorrect. The training includes evaluating the healthcare provider's current medical documentation process, training the healthcare provider in methods of recording medical documents, providing a system for recording medical documents, and training the healthcare provider in use of the system.

1 . A method of recording a patient's medical documents comprising:
 a. obtaining medical data from the patient, wherein the data comprises disease codes;   b. storing such data obtained in step (a) in electronic medical records embodied on a computer readable medium;   c. evaluating said data stored in step (b) via a computer capable of interpreting said electronic medical records to ensure that the data entry is complete; and   d. presenting a notification if any of the data evaluated in step (c) is found to be incomplete or incorrect.   
     
     
         2 . The method of  claim 1 , wherein the disease codes are ICD- 9  codes. 
     
     
         3 . The method of  claim 1 , wherein the evaluation in step (c) comprises evaluating whether for each disease code there is recorded a corresponding diagnosis of the disease, status of the disease, and plan of action for the disease. 
     
     
         4 . The method of  claim 1 , wherein the evaluation in step (c) comprises evaluating the obtained disease code to determine whether an improper code has been entered. 
     
     
         5 . The method of  claim 4 , wherein the obtained disease code is evaluated to determine whether a more specific code should be used. 
     
     
         6 . The method of  claim 4 , wherein the evaluation of the obtained disease code is determining whether a current disease has been improperly coded as a history of the disease. 
     
     
         7 . The method of  claim 1 , wherein the evaluation in step (c) comprises evaluating whether there are likely disease codes that have not been obtained in step (a). 
     
     
         8 . The method of  claim 7 , wherein if a diabetes code is obtained in step (a), a notification in step (d) is presented to the user that complications of diabetes should be properly coded. 
     
     
         9 . The method of  claim 1 , wherein the data obtained in step (a) further comprises medication prescriptions of the patient. 
     
     
         10 . The method of  claim 9 , wherein the evaluation of step (c) determines whether there is a linking disease code for each medication prescription. 
     
     
         11 . The method of  claim 1  further comprising presenting a notification to the user of the system to review the medical records for commonly unreported or miscoded diseases within a population of patients. 
     
     
         12 . The method of  claim 11 , wherein the commonly unreported or miscoded diseases are selected from the group consisting of chronic kidney disease, neuropathy, peripheral vascular disease, and malnutrition. 
     
     
         13 . A method of training healthcare providers to properly record medical documents, said method comprising the steps:
 a. evaluating the healthcare provider's current medical documentation process;   b. training the healthcare provider in methods of recording medical documents;   c. providing a system for recording medical documents, wherein the system comprises:
 i. a computer readable medium capable of storing medical data obtained from patients, wherein the data comprises disease codes; 
 ii. a computer with software capable of evaluating the data stored on the computer readable medium for completeness; and 
 iii. a notification system capable of presenting to the user of the system a warning if any of the data is found to be incomplete or incorrect; and 
   d. training the healthcare provider in use of said system.   
     
     
         14 . The method of  claim 13 , wherein the training provided in step (b) comprises instructing the healthcare provider to ensure the medical documents are sufficiently detailed and coded to achieve the correct RAF score. 
     
     
         15 . A system for recording medical documents comprising:
 a. a computer readable medium capable of storing medical data obtained from patients, wherein the data comprises disease codes;   b. a computer with software capable of evaluating the data stored on the computer readable medium for completeness; and   c. a notification system capable of presenting to the user of the system a warning if any of the data is found to be incomplete or incorrect.   
     
     
         16 . The system of  claim 15 , wherein the notification system presents a warning if a disease code does not have a corresponding recorded diagnosis of disease, status of disease, and plan of action for the disease. 
     
     
         17 . The system of  claim 15 , wherein the notification system presents a warning if an improper disease code has been entered. 
     
     
         18 . The system of  claim 15 , wherein the notification system presents a warning if there are likely disease codes that have not been recorded. 
     
     
         19 . The system of  claim 15 , wherein the notification system presents a warning if a medical prescription is recorded without a linking disease code for the medication.