Patient Questionnaires

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Patient Questionnaires

Postby schnarchendtech » Thu Jul 17, 2014 11:48 pm

Our hospital lab currently uses ESS and Berlin questionnaires. Our non-sleep manager said it is not important and is not and cannot be an official document of the hospital. How important are these questionnaires for patient/ lab use? What are the sleep questionnaires are you using? Thanks in advance.
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Re: Patient Questionnaires

Postby Narco » Fri Jul 18, 2014 3:42 am

schnarchendtech wrote:Our hospital lab currently uses ESS and Berlin questionnaires. Our non-sleep manager said it is not important and is not and cannot be an official document of the hospital. How important are these questionnaires for patient/ lab use? What are the sleep questionnaires are you using? Thanks in advance.


That depends. On your managers part, his concerned more of official documents to be issued to the px. On the Tech side, it gives us an idea of patient status that needed to be validated.
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Re: Patient Questionnaires

Postby somnonaut » Fri Jul 18, 2014 4:07 am

Tthe questionnaires should be used for follow-up against the same questionnaires used at a later time. Compliance with therapy as gauged against subjective feelings, point A vs. point B..
Or is his/her issue with scanning the paper and the saving of computer hard drive space, and/or ease that creating an electronic document is, as compared to recording the values electronically in the chart and having to keep the paper for paper's sake?
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Re: Patient Questionnaires

Postby bduce » Fri Jul 18, 2014 4:25 am

1. What is the manager's rationale for stating that it is not important? According to what? Money? Quality of care? What prism is he viewing this from?
2. I may be daft at times but wouldn't these questionnaires be useful in corroborating the need for sleep studies if the insurance provider wishes to query payment for the studies? Happy for one to correct me as I'm not a party to this health system.
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Re: Patient Questionnaires

Postby Water Boy » Fri Jul 18, 2014 8:33 pm

Thats crazy, documentation is everything and digital storage is cheap.

We have to collect ESS and a 5 page sleep hx qx from the patient for review by our medical director for any patient who does not have a consult with a boarded sleep specialist on staff, I think AASM requires all that to be in the permanent chart along with documentation that med dir signed approval that the patient H and P and order for testing are all compliant with AASM clinical guidelines and practice parameters, and they do look for it when they site visit for reaccreditation.

Also, most HMOs now require us to submit a patient sleep history qx to obtain authorization for any in-lab sleep testing, which of course they then use to try to redirect the patient to home sleep testing (appriopriate or not), and we have to submit more data or have a peer to peer conference (if the ordering physician is willing) to redirect the redirection, i.e. convert the auth back to an in-lab. Carecentrix (an HMO intermediary with sole purpose to keep patients away from sleep labs) is notorious for huge amount of documentation required for authorization, patients commonly wait for 2 to 3 weeks while we chase papers, sleep hx qx, Epworth, H and P, neck circumference, doumentation of comorbities, etc. All of that has to be retained.

Also, CMS hires outside auditors that perform a RAC audit, even years after a sleep study, and if you can't produce all the above documents (they are listed in your LCD), you have to pay back all the $ you were paid. Some local sleep care providers here have been hit very hard by these, even to the point of closing down. Medicare pays the contracted auditors a percentage of what they recover so they are pretty aggressive looking for any missing piece of information they can use to retroactively deny payment.
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Re: Patient Questionnaires

Postby schnarchendtech » Fri Jul 18, 2014 8:57 pm

I spoke to our manager again. I think what He was concerned about going paperless.
We all know that these documents are very useful and these tools are also used by physicians.
He pointed out that the answers or the total score ( for the ESS ) for instance be included in the electronic medical record.

So, after patients filled all these papers and if we had included all in EMR, then all goes to the garbage I guess since it's not considered an official document.

Do you do the same for those who are working in a hospital based lab? How do you make a non-official document official? I got all the consultants' approval and I thought that would make it as an official document.
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Re: Patient Questionnaires

Postby somnonaut » Sat Jul 19, 2014 1:18 am

AFAIK anything you wish to include in a chart automatically becomes official.
DO NOT put the items scanned or transferred into the EMR into the 'garbage." They must be shredded as HIPAA containing documents.
The amount of hurt created by NOT attaching a single piece of external paper is no where near the hurt or cost associated with scanning and attaching said document. As Water boy clearly, and rightfully points out.
The EMR should not be considered so much as a sacrosanct "document" in and of itself, to be an electronic, pristine, oasis, free from the contaminants of hand written documents. But more like a convenient electronic filing system where the things you put in are not just electronified, but also become automatically able to be searched, sorted, cataloged and cross referenced, allowing a multitude of analyses and manipulations/visualizations and shared. If one day, an insurer wants to SEE the document (pt questionnaire) and not just have the values regurgitated to them, then you would be hard pressed to get a representation of that document (with pt signature) again if it was only transferred into the EMR electronically and not scanned in as a document. These are some of what are called "source documents." They are the source for the initial contact with the provider. It is best to keep EVERYTHING.
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Re: Patient Questionnaires

Postby schnarchendtech » Fri Jul 25, 2014 8:16 pm

Somno, we are not placing these items directly in the bin. Of course , these are shredded. My apologies. I think we are doing pretty much the same with all patient records as you all shared here.
Water Boy, yes I agree that at times the craziness of documentation is tiring but left with no choice. I haven't heard of any lab in my area getting into trouble yet, and we don't wanna wait for that. :lol:

Thank you everyone for shedding light on this topic. :) :)
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