Putting Your Documentation Ducks On The Health System Environment

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

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.

Two organizations migrating to a common health information system would need a system that meets current regulatory requirements, meets the needs of the combined organization and their practice environment. The implementation of a common health information system would require an interdisciplinary group of forward thinking innovators, and an interoperable electronic medical record system that includes standard nursing terminology.

Job descriptions, procedure manuals, and office handbooks are critical to the success of a medical office because they

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).

Healthcare is an evolving system in the United States; constantly changing as a result of regulations like the Affordable Care Act or because of the large financial burden healthcare presents to many individuals. The system is moving from a fee-for-service system to one that holds healthcare organizations accountable for the health outcomes of the individuals it serves. Certainly for the consumer, these changes are beneficial, but for a healthcare organization, it can be like navigating a mine field, and for a new organization, there are numerous challenges. This paper will discuss the implications of opening a primary care physicians group in the outer belt of Washington, D.C. The focus will be on office configuration, scheduling

Maintaining compliant job reference aids and documentation templates is the next step. This deals with the fact that many medical practices often keep templates, or reference sheets for the most commonly used codes. If not used

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:

Patient care documentation has several uses. The primary purpose of patient care is to communicate vital information about the patient between healthcare providers. Patient documentation also serves to establish a basis for planning treatment. With patients status re ordered you can see what progress has been made and what needs to be done. Another use of patient documentation is quality care management. Management teams can utilize the information within patients records to determine the standard of care that patients are receiving. These records can also demonstrate whether or not a facility is operating sufficiently, or if training may be needed. Another extremely

Lindsey, I understand that it is a real challenge for you, to work in an environment where there are multiple documentation systems. I agree with you in that if there is a unified system in documentation throughout the organization, it could improve the communication among all the departments. Moreover, it could increase the efficiency and safety of care as well as decrease many errors. The electronic health record (EHR) enables a seamless flow of health information about the patient (Government Health Information Technology, 2015). It helps to take the maximum advantage of the advanced technology if used properly in the patient care delivery. By using a unified system, throughout the organization, it is possible to make the information available

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.

The specific problem this research paper addresses is whether the establishment of state standardized documentation protocols can reduce poor documentation of care in hospitalized in-patients in acute care facility. The significance of this clinical problem is to show that state standard legal document protocols can lead to better patient outcomes and improve quality of care. Nursing documentation of care is very important in patients outcome, hospital administrators, practitioners and researchers regards recordkeeping as a crucial and valuable component resulting to compliance, continuity care, safety and quality of care. According to Okaisu, E.M., Kalikwani, F., Wanyana, G. & Coetzee, M., 2014), “to achieve improved documentation, broader changes were necessary, including building a critical mass of competent staff, redesigned orientation and continuing education, documentation form redesign, changes in nurse skill mix, continuous leadership support and legal monitoring”. Assessment in nursing care is the initial standard of

The specific problem this research paper addresses is whether the establishment of state standardized documentation protocols can reduce poor documentation of care in hospitalized in-patients in acute care facility. The significance of this clinical problem is to show that state standard legal document protocols can lead to better patient outcomes and improve quality of care. Nursing documentation of care is very important in patients outcome, hospital administrators, practitioners and researchers regards recordkeeping as a crucial and valuable component resulting to compliance, continuity care, safety and quality of care. According to Okaisu, E.M., Kalikwani, F., Wanyana, G. & Coetzee, M., 2014), “to achieve improved documentation, broader changes were necessary, including building a critical mass of competent staff, redesigned orientation and continuing education, documentation form redesign, changes in nurse skill mix, continuous leadership support and legal monitoring”. Assessment in nursing care is the initial standard of nursing practice, which means, adequate assessment is very

In the Boston marketplace, most hospitals are replacing their current clinical software with Epic. Epic is a fully integrated system that incorporates all aspects of patient care from clinical information, registration, all the way to patient scheduling and billing. While other systems may offer some of these functions, they are typically the products of individual modules, developed by private companies and brought together for daily practice. For this reason, these systems are rarely compatible and fail to provide standardized platform for clinicians and healthcare providers (CareConnect, n.d.)

These shifting dynamics have exacerbated the incessant challenges of medical group practice. Keeping up with new rules, regulations, and technologies has demanded increasing time commitments, creating new pressures over subjects like work distribution and on-call coverage. Moreover, decision-making about fundamental business choices have