Patient Documentation And Medical Procedures

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.

A medical office administrative assistance must know the importance of proper medical documentation,the legal aspects of documentation and the various medical laws, regulations, and acts; understand language and other communication barriers, proper billing and reimbursement procedures, workplace conflict and diversity; and know how to properly maintain patient ledger cards. Accurate medical documentation ensures the patient receives the proper treatment and aides in validating medical necessity. This documentation is not only critical to the patient but the facility as well because it ensures proper codes are assigned, clean claims are submitted, and allows the reimbursement process runs smoothly. Medical office administrative assistants must understand the imporatance in protecting patient privacy because they have an ethical and legal

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

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.

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).

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,

“In general, people under the age of majority … have fewer rights and responsibilities than adults. For example, you must be 18 to vote, enter into legal contracts, or purchase a lottery ticket in most states. But states, including Tennessee, also recognize that people under the age of majority still have to make certain decisions on their own, and may not benefit from a parent's consent.” (3)

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

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:

During my clinical competency placement, I was working on a surgical ward when a registered nurse on duty asked me to assist Mr. A with his shower. This incident happened on the fifth day of my clinical practice. He was a dementia patient and had undergone right knee total joint replacement. She also informed me that the patient did not like too many people in his room because of his dementia. When I went into his room, his wife was there with him. I talked to the patient about having a shower and getting dressed to look smart and he agreed to have a shower. The patient got out of the bed and walked to the bathroom and sat on the shower chair to have his shower. Then I asked his wife if I needs to stay with him to assist with shower, she said she can help him as she was taking care for him at home since he has been diagnosed with dementia. Therefore, I left the patient with his wife to help with his shower and told her to ring the bell if she needs any help. After some time I left the room, the wife rang the bell. As soon as I entered the room, I heard him shouting at his wife and she started crying and left the hospital. So I had to stay with him. He was very capable of washing himself and I just had to help him wash his back as he requested. After he had washed, I asked him if he was ready to get out of the bath, he started shouting at me.

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

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

There are many different variations of healthcare professionals that assist people in regaining and maintaining a healthy lifestyle. The career field of licensed nursing is often considered to be one of the most vital professions within the medical community. Registered nurses work to prevent and heal various different types of injuries, diseases, and illnesses. They are also responsible for administering a variety of patient services, consisting of individual patient care, analyzing and monitoring patient medical reports, and also possessing the ability to operate technical medical equipment. As well as, be able provide comfort and emotional support for both physically, and mentally ill patients. All Registered Nurses are responsible for providing patients with quality health care, in compliance with professional standards set forth by the American Nurses Association. As the field continues to rapidly evolve, an increase in responsibility is placed upon registered nurses to maintain a professional standard of care. With the increase in responsibility, the role of registered nurses consistently changes to accommodate individual patient needs. As a result, the rise in responsibility placed on registered nurses correlates to a higher probability of malpractice and negligence occurring within the community. The consequences of malpractice and negligence can