Documentation Records NCQA

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.

Provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people

According to Chtourou (2013), a CDI program focuses on enhancing the accuracy of clinical documentation quality which requires a huge input from CDI specialists, heath information management professionals, coders and clinicians to collaborate together to review the quality of documentation reported/captured in order to ensure accuracy and complete of patient’s clinical encounter. As a healthcare provider, medical records that are incomplete or inaccurate often times, compromise the quality of care reporting and inevitably affect the clinical decision support system of the organization including the accuracy of reimbursement. This is reasonable since the CDI program has emerged as a new paradigm to meet the changing needs of maintaining a sound health record documentation across the healthcare industry (Hauger, 2014). Most of the CDI programs have to a great extent concentrated on boosting the Diagnosis-Related Groups (DRGs) installments by securing clinical documentation to support medical complications and co-morbidities (Hauger, 2014).

HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.

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

The Care Quality Commission makes sure that hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high quality care, and they encourage these services to make improvements.

Bi: the role of CQC; care quality commission, is to set out standards of care that need to be met by all members of staff. Also regular inspections will take place in the health care

The value of CDI clinical documentation improvement (CDI) programs are important to any facility that recognizes the requirement of complete and accurate patient documentation. Documentation is very critical because it validates the care that was given. Furthermore, it shares important data to the caregiver and improve claims processing (Leventhal,2014). The three challenges are getting physicians to buy into the program, physicians are extremely busy so they are not connecting the dots on clinical documentation, and training the physicians to get them to understand they need to do better documenting (Leventhal,2014).

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 1994 the American Nurses Association (ANA) started the Patient Safety and Quality Initiative. It was a pilot program designed to evaluate the links between nurse staffing and quality care (Montalvo, 2007). The program outcome was a set of nursing-sensitive indicators used to evaluate quality care for patients in the acute setting and the start of the National Database of Nursing Quality Indicators (NDNQI). The NDNQI is a

Although the overall state of compliance for the organization is good, there are several areas that have been identified as “Priority Focus Areas” due to a past history of nonconformities. All these areas are related to Information Management and Record of Care, Treatment, and Services, in particular:

The Australian Commission of Safety and Quality in Health Care (ACSQHC) was established in 2006 by the Australian Government to improve safety and quality in healthcare. In 2011, the ACSQHC developed the ten National Safety and Quality Service Standards (NSQHS) in order to improve the safety and quality of the Australian healthcare system. The ten standards were also implemented to ensure that the public is protected from harm and that consumers or patients can expect a certain level of care from the healthcare systems. The standards are now compulsory for many healthcare organizations.

What is a patient medical home? A patient medical home is a model of care designed to foster a partnership between the patient and the physician. The New York State has adopted the medical home standards of the National Committee for Quality Assurance (NCQA). The National Committee for Quality Assurance (NCQA) defines a patient medical home is "a model for care provided by physician practices aimed at strengthening the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship.” The NCQA is a private, 501(c) (3) not-for-profit organization founded in 1990. The organization is dedicated to improving health care quality.

Proper documentation can mean the difference between receiving and not receiving reimbursement for services the physician performs (Andress, A. A. (2009). If the documentation is not recorded properly, billing codes cannot be entered correctly; this can cause a denial in payment or cause payments to be delayed. It can also cause a patient’s medical record to not have all the critical documentation needed for them to receive the best possible care. There is a requirement for documentation of quality medical care and the outcome of the care before being able to renew contracts with managed care organizations (MCO). Proper documentation also reduces liability for the medical office and reduces the chance of triggering an audit.

     Documentation is the means by which we communicate our treatment to other health professionals and third party payers. In most cases, it is necessary to communicate effectively to others, orally and in writing the status of the patient. In addition, documentation is an important aspect of our field because it conveys the status and condition of the patient and our plan and evaluation of said condition to other caregivers. Medical records will be read by the doctors, nurses and in some cases by those submitting payment to the insurance companies. It is important that as occupational therapy students we develop documentation skills early and continue to refine these skills throughout our careers.