I asked for clarification from CMS regarding the focused exam. CMS response: If the physician documents "exam completed" it would be sufficient documentation that an exam was performed.
I hope this helps. Jennifer Osburn, RN, BSN Performance Improvement St. Mary's Medical Center 304-526-1506 [email protected]<mailto:mailt:[email protected]> Confidential & Privileged Peer Review/Quality Improvement Activity Pursuant to West Virginia Code 30-3C-1, et seq. and Ohio Revised Code 2305.25, et seq. Important Notice: This e-mail message and any attachments are from the above sender at St. Mary's Medical Center and are intended solely for the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you are not the intended recipient of this communication or the employee or agent responsible for delivering the message to the intended recipient, or if it has been sent to you in error, please notify the sender immediately. Do not examine, review, use, disclose, deliver, distribute, reproduce or take any action in reliance on it and immediately delete the message and any attachments. From: Sepsisgroups [mailto:[email protected]] On Behalf Of Tish Poserina Sent: Tuesday, January 31, 2017 9:05 AM To: [email protected] Subject: [Sepsis Groups] Focused exam 2017 Can I get a clarification re focused assessment? Most recently, if a physician documents "a sepsis exam" or "perfusion exam" completed, would that prompt the abstractor to say "yes" to the components required for a focused exam? And if so, would that still mean the components must be documented individually in the record? I may be mis-interpreting the latest CMS update. Thank you Tish Poserina RN, MSN-Ed, CCRN-CMC, CNRN Sepsis Coordinator St Mary Medical Center 1201 Langhorne-Newtown Road Langhorne, PA [email protected]<mailto:[email protected]> Contact: 215-710-4347 Spectralink: 215-710-7644 [stmaryLOGO][trinity logo] Confidentiality Notice: This e-mail, including any attachments is the property of Trinity Health and is intended for the sole use of the intended recipient(s). It may contain information that is privileged and confidential. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please delete this message, and reply to the sender regarding the error in a separate email. Important Notice: This e-mail message and any attachments are from the above sender at St. Mary’s Medical Center and are intended solely for the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you are not the intended recipient of this communication or the employee or agent responsible for delivering the message to the intended recipient, or if it has been sent to you in error, please notify the sender immediately. Do not examine, review, use, disclose, deliver, distribute, reproduce or take any action in reliance on it and immediately delete the message and any attachments.
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