Clinical documentation improvement
The importance of clinical data in a medical record cannot be over emphasized. Clinical documentation of patient care is very important for various reasons to various organizations. Physicians use the patient’s health records to make assessments and plan their course of treatment. Government policies regarding the general well being of the population is based on the data collected from medical records. Healthcare organization’s reimbursement for the services provided is dependent on the coded data submitted to the third-party payers. Coders can only code what is in the medical record, so if it is not documented properly it is not going to get reimbursed. In case of a lawsuit, clinical documents become very evident. CMS requires that patient’s all medical conditions and treatments as well as patient’s past medical history to be documented in the record. Any error in recording the data could pose grave danger to the life of the patient; it can result in ineffective policies or even pose the financial burden on the organization if the reimbursement is affected. The HIM department plays an important role in maintaining the quality of patient care by ensuring
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This practice leads to incomplete or unspecified information on the record. Because of the introduction of the CDI program in the healthcare organizations, the review of medical records start after the first 24- hours of the patient’s admission. The medical records are reviewed continually during the entire course of the patient treatment in the hospital. CDI specialist who has training in disease processes, coding, rules and regulations of the healthcare organization and the contents of the medical record review the records persistently to make sure it has all the details needed for the accurate code assignment. Some of the criteria for the reviews are (as described in
In the medical billing and coding process there are several steps. In the medical billing process physicians prepare and sign documentation of the patients visit. The next step is to post the medical codes and transactions of the patients visit in the practice management program and to prepare claims. The process used to generate claims must comply with the rules imposed by federal and state laws as well as with payer requirements. Claims that are correct help to reduce the chance of an investigation of the practice for fraud and also the risk of liability if an investigation does occur (Valerius, Bayes, Newby & Seggern, 2008). Most physicians depend on their personnel to process their medical bills without looking at the bills before they’re submitted for payment. Some physicians who don’t review the medical billing procedures may not receive the payment they deserve (Adams, Norman, & Burroughs, 2002).
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...
Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole.
chartings in the medical record of a patient, taking the patients vitals and reporting abnormal to
... basic information of the patient. Professional and precise language should be used when documenting. For the care plan, I have learned to correctly write a nursing diagnosis and writing interventions that are within nurses’ capability and suits the patient’s personal status. From now on, I will remember to distinguish medical diagnosis from nursing diagnosis. For each diagnosis, I will write about the patient’s (potential) response to the health problem and state why this might be the concern.
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..
...e expanding role of the HIM professional: Where research and HIM roles intersect. Perspective Health Information Management, 7(1). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2047329/
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
This paper will show how assessment is a core part of the client’s treatment. It will show how assessment is done at the beginning of the treatment process but, will allow you to see that assessment is a continuing process. It results from a combination of focused interviews, testing, and record reviews. Assessments give the social worker a framework of reference to understand the strengths, weaknesses, problems, and needs of the client for the development of the treatment plan. It provides the social worker with a theory-based framework for generating hypotheses about the client’s experience and behaviors, which in turn helps prepare the basis for a specific treatment intervention. This paper will discuss the assessment tools
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.
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,
There are a number of ways in which patient care can be improved with a facility that utilizes multiple charting systems. The simplest way to provide effective quality care is to implement the EHR. A EHR is an electronic system consisting of a complete patient medical health history of past and current conditions (Keller, 2016; Menachemi & Collum, 2011). In addition, to the patient’s demographic, diagnoses, medications, treatment plans, allergies, laboratory data, immunizations, and test results. EHR decreases medical errors such as misinterpretation of clinical notes, doctors orders, not having access to paper chart that have yet to be filed or has been missed file (Keller, 2016). EHR also allows for quick and easy access to diagnostic test results and patient notes that are needed for patient care. EHR will significantly enhance patient care by reducing the amount of time it takes the healthcare team to retrieve the needed health information to deliver patient care. It will also dramatically reduce medical errors that are associated with the nursing staff manually entering doctors’
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
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