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  1. eCQM Issue Tracker
  2. CQM-2925

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    • Icon: EC eCQMs EC eCQMs
    • Resolution: Done
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    • Jennifer Niehus
    • 580-548-1782
    • Integris Bass Baptist Health Center
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      We cannot comment on backdating entries within your medical record. It is unclear if the scenario you describe is for infants who had a hearing screening performed prior to having a critical need to transfer to another facility. But EHDI-1a does include a clause for the diagnostic hearing screen not done due to medical reasons (contraindications). A medical contraindication means there is a reason to withhold a certain medical procedure/treatment because it could harm a patient. If an infant needs a transfer out because he/she is critically ill, either medical reason or contraindication can be used. However, if the infant is not critically ill, neither “medical reason” nor “contraindicated” are valid. Newborns can transfer out even when they are healthy. Hospitals should not use medical reason for all transfers indiscriminately.​
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      We cannot comment on backdating entries within your medical record. It is unclear if the scenario you describe is for infants who had a hearing screening performed prior to having a critical need to transfer to another facility. But EHDI-1a does include a clause for the diagnostic hearing screen not done due to medical reasons (contraindications). A medical contraindication means there is a reason to withhold a certain medical procedure/treatment because it could harm a patient. If an infant needs a transfer out because he/she is critically ill, either medical reason or contraindication can be used. However, if the infant is not critically ill, neither “medical reason” nor “contraindicated” are valid. Newborns can transfer out even when they are healthy. Hospitals should not use medical reason for all transfers indiscriminately.​
    • CMS31v5/NQF1354
    • false failures. Babies are receiving hearing screens by a contracted vendor who does not have access to the EMR. Occasionally documentation is not completed before discharge by the nurse.

      Our baby hearing screening is done by an outside vendor who does not have access to document in our EMR. When we have a critical baby that the nurse is transferring to another facility the baby may get discharged prior to the nurse completing her documentation. If we have the paper document of the baby hearing screening scanned into the chart with the date and time it was completed, can we back date and time our EMR record to reflect the date and time on the paper document? if yes, is there a time frame this is allowed? Example if documented within 4 hours of discharge and the paper document is scanned into the chart it would be acceptable to back date and time the EMR to match the paper document.

            JLeflore Mathematica EH eCQM Team
            niehjc Niehus (Inactive)
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