Missing Accurate Medical Documentation Essay

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.

In any medical facility, the number one reason for maintaining medical documentation is to ensure continuity of care for the patient. Good medical documentation supports decent communication between patients and doctors for different reasons. Recording all important information help the doctors monitor the patient’s medical history, develop the patient’s treatment plan, and minimizes the risks of errors being made. If there are any mistakes it can jeopardize the patient’s well-being. It may also lead to malpractice lawsuits. In CMSW, the major problem I noticed is that they have issues in setting up their computer patients’ folders and keeping it organized.

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.

Research indicates that as many as 13% [Smith 2005] of primary care visits have missing clinical information. A patient's health information is potentially distributed across a wide range of locations including their general practitioner, hospitals, imaging centers, specialists and allied health practices.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

You are letting the provider know what the patient chief complaint or reasoning is to be seen at the office that day. All information the patient has prior will be beneficial for the process of the claim.

Patient Check-In and Check-Out - If this is the patient's first visit, forms are required to be filled out, a copy of photo I.D. and verification of insurance card is accessed.

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).

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

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

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.

Privacy legislation and the legal complexities surrounding the ownership and management of patient information, many physicians are wary about when they may or may not release such information to patient and other parties. All patients have the right to the information in their medical records. In certain situations the physicians have the right to refuse the release of patient information to the patient, if the have any reason to believe that the disclosed information would have a reverse effect on the patient’s mental, physical, emotional health, or cause harm to a third party. When needed to be transferred a copy of the information may be sent directly from the former physician to the new one. In other circumstance the patient can receive the record themselves and hand it directly to the new physician. It is recommended that the original files are not released, instead a photocopy or scan of it may be sent. A physician may release patient information to lawyers and other parties when requested to do so only if the patient or the patient's substitute decision-maker has given authorization, preferably in writing, or if authorized by law or a court order.When information is

4. While they are being seen by the physician, an encounter form is bing filled out regarding the symptoms, diagnosis, and treatment of the patient. This form will then be given to receptionist at the end of the visit.

The front office staff should review paperwork making sure all required information is filled out (clearly written and legible) Most importantly the Patient Agreement is signed by the patient. It provides added assurance of payment when a claim settles and additional legal leverage should it become necessary.