Successful Clinical Documentation

This standardized dialect is also pertinent for medical schooling and teaching in addition to clinical research and studies conducted by scholars, scientists, and physicians by providing a valuable foundation for domestic and coast-to-coast operation evaluations. CPT is used to describe doctor’s services, a vast amount of administrative services in addition to operating services executed in medical facilities, treatment care centers, and outpatient divisions. Providing support for clerical duties and functions such as processing medical claims and initiating strategies and procedures for the evaluation of clinical care is another cause of relevance for CPT. The system also meets the need for tracking trends and identifying improvements, plus progression goals and scaling the value of healthcare services received by patients. The CPT coding system provides physicians throughout the United States with a consistent method for classifying and coding clinical procedures which in return provides a more efficient tool for recording and reporting task that were completed. Physicians, scholars and payors, have been dependent upon CPT to interconnect with other fellow associates, patients,

In fact, in some instances, doctors find it more difficult to complete with their already hectic and demanding schedule. The article describes the medical records used in the UK which is an envelope of information that follows a patient their entire life. The providers know what to expect when viewing these records and are able to efficiently and effectively use them as a resource when seeing patients. A main takeaway from this article regarding medical records from the UK is that they must be well kept and organized and also keep the same geographical layout and consistency to be effective. By gathering and reporting information in this way, it allows the provider to be concise. The short notes are almost like clues for a future provider about what the previous encounter entailed and how the issue has progressed or regressed. The article discusses VAMP, the “Value Added Medical Products” computer system which is how the United Kingdom does electronic medical records. Their goal was to replace paper records with this type of system, however it did not work out that way. In this type of reporting, there is both a medical file and a therapeutic file which allow the doctors to separate what they are recording. There are many negatives and positives of a computer system such as this one such as it may remind a physician of a treatment or prescription that was given

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

This style of documentation standardizes the communication between the health care team, providing information and a sequence in which both parties know what to expect. The format allows data to be recorded in for basic categories which include Situation, Background, Assessment, and

One technique that has shown tremendous promise is clinical documentation improvement (CDI). CDI helps physicians and coders increase coding accuracy and properly depict the quality of care delivered. CDI aids in communication as well as identifies those areas of the documentation process that could use some improvement and greater specificity. With proper implementation, CDI offers both procedural and financial benefits.

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.

On the other hand, many physicians do not know the importance of the program. In this case, there is an extensive amount of pressure on organizations for them to perform quality care, use correct coding, and get measured accurately through the MACRA. In addition, engaging physicians with their clinical documentation process may be an important factor though a difficult task in all healthcare organizations. Clinical documentation has become a critical part of every patient encounter. In terms of meaningful use, it must provide efficient, accurate, and timely services because it is what patients depend on. The clinical documentation improvement (CDI) program is intended to facilitate an accurate depiction of the clinical status of patients as it gets transferred into coding. At the same time, coded data has the responsibility to report physician’s clinical information, reimbursement, and tracking trends. Physicians must have the right education towards coding necessities, which is vital to correct reimbursement and quality reporting under MACRA’s quality payment program. Essentially, clinical documentation improvement (CDI) programs must be implemented into physician practices as it helps educate them on the general specifications that documentation and certain practices for the ICD-10

An accurate and specific documentation of universally accepted set of codes are important for the protection of healthcare providers as well as increased reimbursement for services received. These codes are for the validation of which services the patient received from their health care provider ( (Page, 2009). Having the correct codes in place insures the provider with the information needed by the health insurance carrier. Maintained by the AMA (American Medical Association), this universal numeric assignment is also used for developing guidelines for medical care review as well as data collection for medical education and research (Scott, 2013).

Coding systems are used in the inpatient and outpatient settings for the classification of patient morbidity and mortality information for statistical use. The World Health Organization (WHO) developed the Ninth Revision, International Classification of Diseases (ICD-9) in the 1970s to track mortality statistics across the world. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), is the adaptation the U.S. health system uses as a standard list of six-character alphanumeric codes to describe diagnoses. Globally utilizing a standardized system improves consistency in recording symptoms and diagnoses for payer claims reimbursement, as well as clinical research, and tracking purposes.

Among other associations, The Association of Healthcare Documentation Integrity (ADHI) has a set of guidelines and standards for their workers. As a registered medical transcriptionist, professionals are expected to uphold both the moral and legal rights of patients, safeguard their privacy, and collaborate with others to ensure patient safety to provide the best quality of care. Through the Code of Ethics ADHI establishes a high standard of conduct that workers in the profession are expected to meet, otherwise they face having their certification revoked from failure to comply. Within the Code of Ethics some of the expectations that professionals are expected to abide by include: maintaining confidentiality of all patient information , implementing

Information in healthcare needs to be meticulous, detailed, appropriate and up to date. It is critical the information we obtain and share on patients is accurate and easily available in an instant. The growth of the information technology industry has grown dramatically in the last 10-15 years, and the healthcare industry recognizes its importance. The mandate set forth in 2004 by the Office of the National

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.

Patton-Fuller Community Hospital is a nonprofit Healthcare organization in the city of Kelsey that has provided quality

There is an accentuation on the need for quality of coded data with the use of computer-assisted coding in healthcare organizations to assure compliance is being met with regards to the increasingly multifaceted quality reporting requirements.

Medical documentation is what shows the quality and continuity of care that the patient receives, it open a communication base between the providers and members about health status, preventive health services, treatment, planning, and delivery of care. Any medical documentation should be written in blue ink entries are dated and authenticated by the author