Clinical Documentation Research Paper

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.

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

The field of healthcare administration is growing at a steady pace to bring about efficient service to all the patients (Harris, 2015). Currently, many specialists have emerged to ensure good health to all individuals at affordable rates. For instance, there is the healthcare documentation specialist, formally known as medical transcriptionists, who are highly-skilled health personnel, dealing with the process of transcribing, verifying, or converting spoken (voice-recorded reports) as dictated by a healthcare professional (Skurka, 2017). The prepared report henceforth becomes part of the permanent health record or history of the patient that can be used in future reference.

When I initially started planning this paper I was ecstatic to learn what the literature had proven effective for the Native American community and possibly my own people, the Navajo Nation. Since I was a little girl I pledged that I was going to help my people, in any way that I could when I grew up. My main drive behind my profession of choice isn’t for the money obviously, I grew up on the Navajo Reservation, and I have witnessed first hand the detrimental effects of alcohol abuse. My father was an alcoholic he died

The Child and Adult Psychiatry, Charito Quintero-Howard, M.D. LLC is located in Towson, Maryland. The clinic service and treat patients of all ages by offering specialized care in all major mental health diagnoses. The mission statement is children, adolescents, adults, and their families be as happy and healthy as possible by providing high quality psychiatric & therapeutic mental health care. Its goal is to, not only treat mental illness by reducing and eliminating symptoms, but also to make the most of an individual's complete mental, physical, and social well-being. Thus, facilitate an individual's efforts at reaching their potential and achieving their goals by providing therapy, medication management, and access

The connections between auditing, accurate diagnostic and practical coding with CDI programs is that the clinical documentation improvement (CDI) is that revising and monitoring offers oversight for the CDI program, understanding into physician documentation and collaboration, and objective assessment of the performance and efficiency of individual CDI staff members as measured against the facility’s policies and

I learned a lot while researching for my topic electronic clinical documentation. As a nurse who has seen many changes in the medical world we live in , I braced myself for the challenges that came when I was informed our clinic would be going live with Epic in 1 year . It seemed like an eternity of classes but the extensive training and time to play in the learning playground of Epic , left me , the providers and the staff prepared for the challenge . Don’t get me wrong, we had some very frustrating days and some very extended hours but the positive aspects of the electronic medical record (EHR) soon out weighted the negative .The long extended hours documenting what we did in the first 3-4 months

The last visit I had with the patient on June 7th, I elected to start him on antihypertensive therapy. He was given a prescription for Zestoretic 10/12.5 mg one p.o. to take daily. He says that he did take one as recommended. That same day in the afternoon, he noted that he was short of breath in the afternoon. He says that he attributed it to the work that he was doing out in the yard and later that day, it seemed to resolve. A few days later, he had the same thing happen again. He eventually went on to see Dr. Lilly on June 25th. Please see that note for complete details. She did have him go through a series of testing, including laboratory studies, which were normal

Clinical practice guidelines (CPGs) are developed based on scientific evidence to improve the quality of care received by patients (Cecamore et al., 2011). According to Barth et al. (2016), clinicians utilizing CPGs provide better outcomes to their patients. The Emergency Nurses Association (ENA) has multiple CPGs for nurses working in the emergency department. One of the CPGs is for wound preparation of acute lacerations.

The clinical documentation components, are the same in a paper based environment as in and electronic health record. However, the important features of electronic records vs. paper are the following:

Explore who you are, uncover your strengths, and work with our trained staff to be your own healer. Our services and care uncover opportunities for you to partner with your provider in your improvement. We use a variety of personalized tools and techniques to address the areas where you can lead a more fulfilling life.

Access to care, long wait times, and rushed visits comprise a few ongoing complaints about the current US health care system that has fueled one of the three major initiatives- to improve the patient care experience (Berwick, Nolan, & Whittington, 2008). A patient’s experience, though multifaceted, is heavily influenced by face-to-face communication with his/her provider, which in today’s healthcare environment includes not only a physician, but also a nurse, nurse practitioner (NP) or physician assistant (PA). The presence of EHRs has undoubtedly affected this face-to-face interaction which was demonstrated in a study done by Alsos et al. where they found that use of a paper chart lead to better “verbal and non-verbal

A doctor walks into the room of a patient where his parents and him are anxiously awaiting the news that he is about to give them. He tells them information they have been praying for: Their son’s cancer is cured. The doctor later walks into a different room with a similar situation. He has to give them different news: Their son isn’t going to live for much longer. Medical field workers have jobs that can be rewarding, but when people see that the medical field has to offer, like the stressful situations, immense amounts of schooling, debt, and constant changes they may want to reconsider becoming a part of it.

I think patient record documentation is to foster quality and continuity of care. It creates a means of communication between providers and between providers and members about health status, treatment, planning, and delivery of care. Try to keep a unique individual record for each patient. Have records organized so its easier for each visit, make sure staff have proper training,and all patient information kept confidential. For example, review a bill to determine if it shows a limited examination or an annual physical with diagnostic tests obtained or requested. If the billing document shows that care was provided, it may be in your best interest to keep the bill for as long as you retain the medical record. And the most important reason for

The purpose of complete and accurate patient record documentation is to foster quality and continuity of care. It creates a means of communication between providers and members about health status, preventive health services, treatment, planning, and delivery of care. www.provider.ghc.org (Links to an external site.)