Basic Medical Documentation

Clinical documentation Improvement (CDI) is the program or the training that is design to provide the good link between coders and health care providers that increase the accuracy and completeness of patient health care documentation. According to American Health Information Management Association (AHIMA) tool kit CDI is the program especially design for health care field for initiate concurrent and, as appropriate, retrospective review of patient health records for accurate, incomplete, or nonspecific provider documentation (Scharffenberger and Kuehn 2011). Most of the time patient health record review occur in inpatient location but it there is any confusion then the review can go through electronic health records too. CDI play a vital role solving complex case between coder and health care provider that result in easy and smooth operation of reimbursement process in health care organization for the service they provide to patient.

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing

Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,

Quality patient care requires the communication of relevant information between health professionals and/or health systems. Healthcare professionals who regularly work with patients and their confidential medical records should contribute to the development of standards, policies, and laws that protect patient privacy and the confidentiality of health records/information.

The careful documentation and subsequent billing process within the course of a patient’s care is an important piece within the healthcare system as a whole. Proper documentation in a patient’s chart relating to any service or procedure is not only important for this patient’s future medical care, but for the facility to receive an accurate reimbursement for the services provided. Reimbursement is affected by every department within the hospital. Healthcare is a business in the long run, and inaccuracies within the reimbursement process will affect the financial stability of the hospital. If a department is mismanaging reimbursement data it could result

As a biller or coder, if it is not documented, it didn't happen that needs to follow to be able to give an excellent service to every patients. Documentation is the key to have an appropriate health patients result including demographics, health issues, and billing. “Consistent and complete documentation in the medical record for every patient is an essential component of providing quality patient care. This documentation is required to record pertinent facts, observations and findings, and must meet certain compliance standards.” If not documented that is not necessary to give any further diagnosis

In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.

Documentation records is related to the quality of patient care provided. It signifies the primary communication among multidisciplinary caregivers for efficient and effective intial treatment, for continuing care, and for the evidence that care and treatment occure. Regulatory agencies use the documentation as a means to measure the quality of services before granting accreditation or certification to healthcare organiztions. Some of those agencies include:

Include documentation in nursing flow sheet, nursing notes, or physician orders. Documentation should be accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes.

Accuracy of recordings and ease of understanding of patient information in medical records play central role in quality of

Guideline compliance of EHR certification body, initiated by the Health and Human Services (HHS), known as the Certification Commission for Healthcare Information Technology (CCHIT) will help establish HIPAA compliance, which includes confidentiality, integrity, and prevention of inappropriate use (Brown, 2009). The CCHIT's primary goals is to verify and ensure eight principles: (1) individual access; (2) correction; (3) openness; (4) individual choice; (5) collection, use, and disclosure limitation; (6) data quality and integrity; (7) safeguards; and (8) accountability (Brown, 2009). The nurse has an ethical responsibility to ensure principles that promote the patient's

A typical day in the office includes auditing claims, sending claims to insurance companies, and working denials. Auditing claims is making sure what the physician coded for is documented and that the codes are correct. Each day I review the physician 's documentation against the codes they put into our system for their patient’s visit. At times when the documentation does not match what is coded, I query the physician and ask them to re-review their assessment and documentation. Below in the section, “Issues and How They Were Resolved” is a couple of examples of when the physician was contacted. I audit multiple claims a day and it is important that each one is suitable before it is sent to the insurance company.

An article by Custdio et al., (2013) discusses the importance of clinical documentation improvement (CDI) professionals and the importance of them with the implementation of ICD-10. These individuals ensure that documentation is correct and detailed enough. One of their main goals is to ensure that the documentation accurately describes the severity of the patient 's illness and what happened during the visit. The health record has certain standards it is held accountable to and each facility may have certain policies to ensuring the record is complete. To ensure accurate documentation, CDI professionals, known as clinical

This paper is on my journey to be Medical Records and Health Information Technician. On every career path there are trials and tribulations that you will have to overcome. With Medical Records and Health Information Technician, you will have to learn skills, abilities, and have to be detailed oriented. Step by step this paper will guide you into becoming a good health information technician by filling you in on my journey. Nothing is an easy journey, but with the proper training and education from the right institution, you will be well on your way in your chosen career path.