This paper will examine numerous issues related to clinical documentation improvement. An overview/description of the Clinical Documentation Improvement (CDI) must be in the paper. The benefits of implementing a CDI program including revenue. The consequences of not implementing such a program to the revenue and health care of the facility.
List and briefly discuss at least six elements of a sound health record; from the perspective of a CDI program emphasis on quality documentation practices. The significant role of physicians as it relates to timely, accurate, complete and legible health record documentation practices and the timely response to physician queries within 48-72 hours upon receipt.
Outline the process of the department’s
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They are Accurate ICD Code Assignment, CPT Code Assignment, Ambulatory Payment Classification (APC) Assignment, Appropriate Reimbursement, Accurate Quality Scores, and Reduction in Claim Denials:
Documentation is necessary for complying with quality measures. Quality information supports care management and making sure protocols are followed.
The 6 criteria for high quality clinical documentation are legibility, reliable, precise, complete, timely, and clear. Legibility refers to the ability to read documentation. It is important from a CDI perspective because the record needs to understand. Reliable means the data is testable and repeatable. It is important because CDI requires the medical record to show medical necessity. Precise means accurate data. The more detailed clinical documentation the better reflection of the patient’s record will be. Complete means all details are there. It affects payment. Timely data means on time and complete. Clear means easily understood. These are important because timely and clear qualities affect payment.
Physicians should be made to understand their main role is documentation for CDI. If the physician does not document the service or procedure it did
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In order to plan properly I will need the cooperation of physicians, and health information management staff. A council of CDI professionals, HIM managers, and medical staff will be convened to look into the benefits of establishing a CDI program. All the various departments listed above will have to be on the same page.
The design of the CDI program should focus on providing education to HIM and physicians in proper CDI documentation procedures. A query process should be developed to simplify interactions between physicians, coders, and CDI professionals. The design should be set up a process to audit and monitor the CDI program constantly. This will enable the CDI team to correct errors easier by allowing them to review errors in real time.
The implementation of the CDI program will now be discussed. The CDI should collaborate with other departments to ensure they adjust to the program. CDI should make other departments aware of that every service and procedure is important to the proper implementation of a CDI program. Necessary education should be provided for physicians and HIM
With clinicians and CEHRT, the ONC plans to improve healthcare quality through interoperability (Office of the National Coordinator for Health Information Technology, n.d.) The ONC will promote more appropriate healthcare decisions in real-time, patient-centered care, and prevention of medical errors (Office of the National Coordinator for Health Information Technology, n.d.). The ONC’s goal is to reduce healthcare costs by addressing inefficiencies (Office of the National Coordinator for Health Information Technology,
This practicum project experience project plan is the initial step in addressing an identified deficiency in the new CPOE/clinical documentation system implemented last year at the medical center at which I am employed. Using the standardized tools of project management, I have presented the project objectives, the global project methodology, and the formative and summative evaluation criteria. To further describe this project plan, a graphical timeline is shown in figure 1. A narrative explanation of the timeline is included in the appendix. Finally, this project plan is supported by scholarly and peer-reviewed literature.
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea...
...f clinical information systems in health care quality improvement. The Health Care Manager. 25(3): 206-212.
Currently, we use the electronic health record system called Computer Programs and Systems, Inc. (CPSI). CPSI is “a l...
Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..
Errors caused by system problems can be prevented by working with your vendor to reset user preferences as needed. In order to preserve data quality and protect patient safety, it is very important that all medical records contain correct information for the safety and treatment of the patient. It is very important to note any cha...
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
Nursing documentation is an important factor of healthcare delivery today. The use of information and communication technology offers opportunities for improving patient care delivery while reducing nurses’ documentation load and increasing the time available for caring for various patient populations (Munyisia, Yu, & Hailey, 2012).
When keeping up with the documents that is needed for the patients there are some acronyms that you could follow to make sure you are documenting the correct information. One of the acronyms that is most commonly discussed in the medical field would be the soap note. The soap note refers to the subjective, objective, assessment and plan. When documenting patients note the S for subjective talks about the patients symptoms and complaints, the O for objective talks about the patients weight, height, temperature, pulse, and blood pressure, A for assessment talks about the lab data, results of studies and reports, P for plan talks about the current formulation and the plan for the patient (Medical Assistant, 2002). Documenting is a critical component to the delivery of healthcare. It is a tool to ensure continuity of care as it serves as a communication tool among healthcare providers, it plans and evaluates a patient treatment, and it creates a permanent record for the future care. Documenting also create a database to evaluate effectiveness of treatment, facilitate research, substantiate billing, and recollect a memory and or/ justify/defend care provider. When completing these documents you will need to make sure these documents are legible for everyone. Abbreviations has led to many medical errors therefore some hospitals have a “DO NOT USE” list of abbreviations. Medical administrative should document every interaction with or about the patient, rather it’s face to face or over the phone (Crozer-Keystone Health System, 2018). Your record serves as a log of communication providing insight into what was communicated with you and patient. When discussing the different legal aspects of a medical administrative assistant you will notice that some of their responsibility differ depending on the size of the practice and the facility. Typical responsibilities of a medical
The patient, in order to have confidence in the health care provider demands that medical chart is accurate
Documentation is one of the vital components of ethical, safe and effective nursing practices that provide comprehensible image of the clients health status and their outcomes. As nurses we must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the multi-disciplinary team.
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,
Documentation is a form of communication that provides information about the patient and confirms that care was provided to that patient. Some reasons why nurses document is for communication and continuity of care of the patient and by that it means clear, complete and accurate documentation in a health record ensures that all those involved in a client’s care, including the client, have access to information upon which to plan and evaluate their interventions. Next, quality improvement/assurance and risk management through chart audits and performance reviews documentation is used to evaluate quality of services and appropriateness of care. Additional reason is it establishes professional accountability because documenting that is showing a valuable method of demonstrating that nursing knowledge, judgment and skills have been applied within a nurse-client relationship in accordance with the Standards of Practice for Registered Nurses. Another purpose is for legal reasons the client’s record is a legal document and can be used as evidence in a court of law or in a professional conduct proceeding. Courts may use the health record to reconstruct events, establish time and dates, and refresh one’s memory and to substantiate and/or resolve conflicts in testimony. Although you may never be named as a defendant in legal case, you may be called to testify at a discovery or