Noncompliance is a frequent cause of patient relapse & or injury that may result in readmissions

•Social – Economic reasons


•Mentally illness/ Addiction/Dementia

•Multiple co-morbidities

•Disabilities (Educational Challenges)


Providers will need to document the indicators to capture the Diagnosis

Documentation in the patient’s medical record concerning refusal of

treatment should include the following points:

  • A notation about the information the provider gave to the patient concerning the condition and treatment, including reasons for treatment or a referral to a specialist

  • A notation that the patient was advised of the risks and consequences of failing to undergo tests or to see a specialist

  • A notation about the patient’s refusal to follow the treatment plan or advice and/or the patient’s signature on a refusal of treatment form

  • Verification that the patient did not keep his/her appt. with the specialist

  • Link the condition that precipitated to the noncompliance

Build a case for why the patient is noncompliant and any steps to rectify the situation, this case( if applicable) should be initiated from the ambulatory setting and carried through to the inpatient admission. simply documenting the patient is noncompliant will not impact on negative readmissions scores-build your case

I am a huge fan of predictive analytics to target 'at risk patients' so the organization can Implement a process to address re-admissions such as:

  • Automate patient engagement:

  • Have return receipt of notification of pending appointments scheduled

  • Have return receipt of prescription fulfillment

  • Automate notification to the provider that a prescription wasn't filled

  • Providers can set lab parameters to automate an office visit

  • A1C @9% with early intervention could prevent further disease exacerbation

I have worked with organizations that have provided necessary medications such as antibiotics to 'at risk' individuals to mitigate a potential surgical site infection and or a CHF exacerbation.



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