Michelle Knuckles, RHIA is the manager of Inpatient Clinical Documentation Improvement and Coding at the University of Utah Hospital. Clinical Documentation Improvement is the vital process of ensuring that records are complete and accurate. There are many types of problems that can occur in patient records, such as conflicting information, inconsistent diagnoses, vague documentation, or illegible information. The accuracy of severity of illness and risk of mortality are also important factors for a CDI professional and the organization itself. If a record has inaccurate MS-DRGs, CCs, MCCs, APR-DRGs, or mortality index; the hospital is unable to truly participate in hospital compare through Medicare and cannot create an accurate picture of their stance compared to state and national benchmarks. The role of a CDI professional is to catch these problems and assist in resolving them which results in a complete and accurate record at the time of the patient’s discharge. CDI is an important part of a patient’s quality of …show more content…
Clinical Documentation Improvement also has connections to reimbursement, quality of healthcare, and public reporting; and facilities rely on CDI for all of it. The process of clinical documentation improvement has a defined list of goals it needs to meet. They are to have accurate Present on Admission documentation, reviews of records going to all payers, accurate public reporting of diseases and illnesses, specific and accurate codes, decrease the volume of third party denials of claims, and reduce risks through recovery audits. CDI professionals also need to be able to work well with people in many different roles as they will work with a variety of departments during their work of ensuring an accurate written
The Beginning Stages of the Writing and Publication Process: Matching the Topic to the Journal
To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible.
At the end of the day, physicians routinely record their patient notes into a tape recorder or other recording device, depositing the resulting medium at the hospital's transcription department. Since most in-house records departments are not 24/7 operations, there is no action on the patient data until the next morning, when the transcription staff types up the information in the tapes. When the transcription is complete, the st...
Greiver, M., Barnsley, J., Aliarzadeh, B., Krueger, P., Moineddin, R., Butt, D. A., & ... Kaplan, D. (2011). Using a data entry clerk to improve data quality in primary care electronic medical records: a pilot study. Informatics In Primary Care, 19(4), 241-250.
Language can be an example of poor documentation practices in patient records because it has to be specific, objective, and factual. An example would be a nurse documenting about a patient “appearing to be looking good” the nurse was using vague words and speculating. There needs to be specific facts that the patient is doing well by documenting the patient’s temperature or the reaction to the medication taking affect. Vague words can cause problems to the healthcare provider because the nurse didn’t describe facts and the provider needs facts to prove that the patient is doing well and not send them home still feeling ill. This could cause problems with the patient because the patient may be feeling the opposite and feel ill instead of good.
Improvement in quality of healthcare: Work in interprofessional teams, employ evidence-based practice, utilize informatics, provide patient-centered care, and apply quality improvement (QI).
...to eliminate healthcare system--based errors through centralized records and other streamlining methods to improve processes. In doing so, it seems likely that our patients will gain confidence in us and our ability to help them navigate a complex and confusing system" (Science Daily 2007, 17)
Patient Check-in: This is the 1st step of the appointment and where the flow begins. The patient arrives to the doctor’s office and signs in on the “check in” clip board, most doctor’s office has one in the front desk. Usually it will ask for some basic information so the person on the desk can verify all information in the system is correct.
Translational bioinformatics: In our ADH program, whenever we have a new admission; the nurses, social workers, and the activity coordinator works together and collect their information from their medical record, health issues, daily activities, and any social services that the patient has. From there, we enter on our database to and follow up every quarterly to see if the patient progress sees if there is any change. For the nurses, they have to constantly do a monthly note on the client and we have to look at those notes to see if the patient needs any assessment if their changes in their mental
Documentation has been explained by so many authors and many studies have been done concerning it. According to Kammie Monarch JD,R.N. Documentation can protect nurses against allegation of negligence and malpractice, preservation of medical records and mistakes commonly made in charting that leave nurses vulnerable to law suit.
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
Clinical documentation improvement for ICD-10-CM ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Establishing accurate/measurable goals and objectives for Clinical Documentation Improvement for ICD-10-CM will ensure the quality of care and better treatment within organizations. This essay intends on demonstrating the clinical documentation
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as “anything which has been entered into a patient’s electronic health record or written in a patient record” (Perry, 2014, p. 47). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014, p. 47). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that, “As regulated health care professionals, nurses are
The process of eliminating coding errors can be very tedious and stressful for medical office managers. Training and more training with appropriate supervision. Managers in coding departments must be proactive in ensuring that employees are properly trained and consistently monitor coding practices for accuracy. In addition, "comparative data is available for all types of facilities to compare their data DRG, APC, or other payment