Healthcare Documentation Specialist 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.

When people think about jobs in the health care field, it can be easy to assume that most jobs involve direct, hands-on patient care. What many people don’t realize is that administrative jobs are equally vital to ensuring quality health care services. Medical billing and coding is an important piece in the administrative puzzle that makes up the vast health industry. As with most administrative jobs, medical coding and billing professionals need to have excellent attention to detail, as one wrong code or inaccurate statement can have an extremely negative

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

In this case, CAC technology also provides a connection between EHR documentation and transcription systems. Primarily, CAC technology in a healthcare environment has rapidly and drastically changed the process in which medical coding in health-information management. This is handled for a better productivity and efficient workflow solution, including production monitoring, coding review, management reporting, computerization of coding and auditing. Clinical documentation is ensuring that it has routinely generated medical codes from computer assisted codes (CAC). In addition, CAC technology has enabled healthcare organizations to recognize the revenue-cycle process as they increase their requirements towards improved quality. The complete implementation of the CAC technology is essential when improving the main necessities towards patients, such as the efficiency, quality, productivity, and management of their care. Last but not least, CAC technology has produced one of the best strategies for the challenges that the HIM professionals face as coding becomes one of the most important aspects of transitioning to

Health Information Exchange (HIE) supports both transferring and sharing of health related information that is usually stored in multiple organizations, while maintaining the context and integrity of the information being exchanged (HIE, 2014). The goal of health information exchange is to expedite access to and retrieve clinical data to provide safe efficient, effective, equitable, timelier patient-centered care (HIE, 2014). HIE “provides access and retrieval of patient information to authorized users in order to provide safe, efficient, effective, and timely patient care” (HIE, 2014).

Providing quality transcription services to customers are key. In the healthcare industry, proper documentation is vital as the records are considered legal documents. These documents

According to Rosenbaum et al. (2015), healthcare documentation combined with clinical communication that is coded for hospitalized patients is an important part of medical care. The paper or electronic healthcare record is then submitted to third party payers that provide reimbursement for services based on the guidelines of the Centers for Medicare and Medicaid Services (CMS), Medicare Severity Diagnosis Related Group (MS-DRG), and inpatient prospective payment system (IPPS) (Rosenbaum et al., 2015). The

Clinical documentation is vital to the success and care every clinical facility provides for their patients. It is a time-stamped process that includes all medical data performed by the hospital. It gives detailed analysis of procedures that were done, reasons why and past medical history. This gives the patient and hospital a detailed summary which helps improves the effectiveness

Recently graduating from Penn Foster’s Career School of the Electronic Medical Records Program; provided me with an overview of how to manage electronic medical records in different healthcare settings whether it is a physician’s office, hospital or urgent care clinic. It also helped me emphasize proper documentation and occupational performance by gaining addition electronic medical records training. My studies and training thus far have guided me in the academic direction that I need to to go into, in order to continue pursuing success.

Accurate and comprehensible medical records documents are crucial for a positive outcome for the patient and health care providers. Health records sequentially convey significant details concerning patient’s health history and future care plans. These records are pertinent when initiating care in the acute and chronic setting for the patient. Medicare, Medicaid, and other personal health care providers necessitate rational documentation to guarantee that a procedure and/or examination is consistent with the individual’s health care coverage. The documentation also authorizes the place of health care treatment, eligible medical requirement and suitability of diagnosis and/or therapy, and that the services rendered were appropriately documented. Precise and reliable medical documentation should be recorded at the time of treatment or shortly after the intervention. Inappropriate documentation can result in erroneous and inappropriate imbursement for provided health care services.

When you look at how nursing documentation affects patient outcomes consider all the benefits of informatics. Electronic charting systems allows for automation in patient safety issues. This automation can be prompts that forces a nurse to address things like abuse history, and many other requirements from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and if the nurses document, there is a history of abuse, the system can automatically send a referral to a department to follow up on the nurses charting. The clinical systems store valuable information, and re-populates, this information on later admissions. An example of this valuable information, would be a patient with the diagnosis of methicillin-resistant staph

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.

Documentation plays a vital role in research, education, quality assurance and reimbursements for both patients and providers (Okaisu, Kalikwani, Wanyana, & Coetzee, 2014, p. 1). The importance of documentation is not lost on any RN, but continuity in what is recorded and what is absolutely necessary to have in a patient’s record is not always met.

Earlier, Medical Transcription was used to be done by using manual typewriters, but with the advancement of technology, electric typewriters replaced manual typewriters and further computers and word-processing software changed the whole system. Today, these medical reports are recorded in digital formats which allow efficient data storage, ready retrieval and provide remote access to patients’ medical reports.

The importance of patient information system is related to different needs and objectives. They constitute the permanent documentation of patient health, permitting the medical professional to evaluate symptoms and signs within a broader temporal perspective, contributing to improvements in making diagnoses and providing treatment. The value of the patient record is also understood within the legal scope because it can be taken to trial, allowing doubts to be clarified and behaviors to be discerned, which, in turn, can protect patients, medical professionals, and other involved parties.