MUSC is now a member of the Care Everywhere network and can exchange records with other organizations, including those out-of-state. Care Everywhere is an application within Epic that provides access at the point of care to a patient's EMR. A provider can print the Care Everywhere authorization form, have it signed by the patient, and have it faxed back to the parent health care facility or provider. This process is similar for outside facilities requesting MUSC data for a shared patient.  

Official DHEC Health Advisory:

Hepatitis B Outbreak in North Charleston, SC Associated with a Spinal Care Clinic

Clinical Documentation Integrity (CDI) Program

CDI Committee - Work Function

The work function of the MUSC CDI Committee is to maintain vigilance of regulatory coding changes that occur routinely on a yearly basis and irregularly during the year. The coding leaders on the committee recognize opportunities for MUSC to gain consistency of terminology, educate physicians, and meet outside expected standards of quality of care. Institutionally, MUSC can establish internal "guidelines" and "standards" for coders to follow when interpreting the clinical documentation record. These are guides and not meant as a "policy."

Specific Examples Where Medical Documentation Drives Guidelines for Coding

The CDI Committee adopted specific guidelines for coders to accommodate the usual pathoanatomic terminology documentation found in the medical record. However, to apply coding guidelines, clinicians must document specific terms in the record.

PORF

An example of this application is for PORF. The terms "distress" or "insufficiency" should be applied as a substitute for the word "failure"; avoid the word "failure" when possible.

DNR

Another situation is the guideline which asks coders to consider the statements such as "allow natural death" and/or allow resuscitation of patient "without chest compression" to be equivalent to "do not resuscitate" (DNR.)

NSTEMI

Another guideline situation references the documentation of "non S-T segment elevation myocardial infarction Type II" versus Type I. For coders to apply the most appropriate code that indicates for quality treatment the patient is not indicated to receive aspirin at time of discharge, then clinicians should use documentation that states "NSTEMI Type II with cardiac demand ischemia."

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