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Overview/description of the Clinical Documentation Improvement (CDI)
EXAMPLE OF overview or description of Clinical Documentation Improvement paper
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Clinical documentation improvement for ICD-10-CM ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Establishing accurate/measurable goals and objectives for Clinical Documentation Improvement for ICD-10-CM will ensure the quality of care and better treatment within organizations. This essay intends on demonstrating the clinical documentation …show more content…
guideline that includes supporting and building on many goals to ensure success. Clinical Documentation Improvement (CDI) system focuses on establishing specific goals that are obtainable through documents, coding, and reimbursement. The goals should address general documentation factors that recommend building a medical practice, such as: 1. Producing medical records that help enhance the reliability/quality of care for patients 1.1. Implementation 2. Providing guidance for their providers towards documentation expectations 2.1. Assessment 3. Maintaining the CDI program. 3.1. Maintenance These goals have the potential to enhance the opportunities for healthcare providers as they accomplish their aspirations.
These aspirations have the ability to improve the care of patients through the evaluation of Clinical Documentation Improvement for ICD-10-CM, which will provide an easy, yet effective way for the user to support their care with the healthcare system. Based on these recommendations analyzed, healthcare providers can recognize issues with the healthcare information procedure methods that they use. 1. Producing medical records that help enhance the reliability/quality of care for patients 1.1. Implementation CDI implementation requires precise queries that allow questions to arise towards physicians in order to obtain additional clarifying documentation. In this case, the documentations will assign detailed procedures and diagnosis codes. Query responses are mainly documented through discharge summaries, progress notes, or a query form that helps keep it as a permanent record. In order for queries to be clinically based, they must first be fact driven and concise to the point. The most ideal time for queries to come about, there must consist conflict, any information regarding a significant procedure, or unspecified codes by making sure providers clinical judgment are not judged. In addition, creating a query process requires the right CDI practitioners and staff members for the job to get complete. This includes specializing formats, such as e-mail, software based, and Internet systems that are capable of tracking the number and types of queries through practitioners in order to aid their coding and documenting
skills. Key implementation factors: • Collaborate with CDI providers in order to implement the required changes in the most effective and efficient way possible for everyone to adjust smoothly. • Create awareness among healthcare practitioners and staff members towards certain tasks. • Pre-planning is essential for the tools and personnel mandatory for successful implementation. • Use results from the audits to perform a customized based program. • Provide the necessary education towards healthcare practitioners in terms of the preparation of the maintenance or sustaining process. • Evaluate the efficiency and effectiveness of the CDI responsibilities in order for the necessary improvements or evaluations to take place. Essentially, quickly identifying compliance with education can be a difficult task because it is best to perform these key implementation factors on a three-month basis. This can help develop new trends to ensure a smooth transition because this should become part of a regular audit throughout the implementation process of ICD-10. For example, unspecified codes through documentation have the ability to both code and bill simultaneously, which will require additional information for a complete code assignment. Since ICD-10 has specific anatomical locations, physicians and clinicians are able to use the ICD-10 system as they communicate the information captured through documentation. Some of the examples of where documentation changes will likely be needed: • Diabetes documentation must include: o Type of diabetes o Body system affected o Complication or manifestation o If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required • When documenting asthma, include the following: o Severity of disease: Mild intermittent Mild persistent Moderate persistent Severe persistent o Acute exacerbation o Status asthmaticus o Other types (exercise-induced, cough variant, other) These are only a couple examples of the specific documentation requirements. As Health Information Management (HIM) professionals continue to review queries and healthcare data obtained from the additional diagnoses, this will require an enhanced documentation system. Thus, ICD-10 is a new environment for all healthcare professionals as it becomes an opportunity to expand and improve the healthcare organizations best practices in order to comply with the challenges of today’s healthcare system. 2. Providing guidance for their providers towards documentation expectations 2.2. Assessment Documentation assessment can be used with ICD-10-CM as the aspirations to improve the education and implementation standards take effect. In this case, conducting gap analyses have the ability to comprehend and determine an organizations strengths and weaknesses, which will be beneficial when recognizing additional issues. An ICD-10 assessment will: • Evaluate and sustain current systems in place for clinical documentation. • Conduct a medical record audit that is able to identify areas, such as improvement and corrections. • Make physician education, training, and consultations part of assessment process.
This practicum project experience project plan is the initial step in addressing an identified deficiency in the new CPOE/clinical documentation system implemented last year at the medical center at which I am employed. Using the standardized tools of project management, I have presented the project objectives, the global project methodology, and the formative and summative evaluation criteria. To further describe this project plan, a graphical timeline is shown in figure 1. A narrative explanation of the timeline is included in the appendix. Finally, this project plan is supported by scholarly and peer-reviewed literature.
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
Medical records are the most basic of clinical tools (Pullen and Loudon 2006) and their main importance is to serve as a form of memoir or aid in client and patient support. Medical records therefore provides essential evidence of care provision, thereby enabling effective communication between health care professionals, members of the multidisciplinary team and all clinicians as a whole.
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea...
...f clinical information systems in health care quality improvement. The Health Care Manager. 25(3): 206-212.
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
Greiver, M., Barnsley, J., Aliarzadeh, B., Krueger, P., Moineddin, R., Butt, D. A., & ... Kaplan, D. (2011). Using a data entry clerk to improve data quality in primary care electronic medical records: a pilot study. Informatics In Primary Care, 19(4), 241-250.
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
This paper will show how assessment is a core part of the client’s treatment. It will show how assessment is done at the beginning of the treatment process but, will allow you to see that assessment is a continuing process. It results from a combination of focused interviews, testing, and record reviews. Assessments give the social worker a framework of reference to understand the strengths, weaknesses, problems, and needs of the client for the development of the treatment plan. It provides the social worker with a theory-based framework for generating hypotheses about the client’s experience and behaviors, which in turn helps prepare the basis for a specific treatment intervention. This paper will discuss the assessment tools
Hence, a Healthcare Reform Bill was passed which resulted in a government mandate that required the implementation of ICD-10. The overall purpose of ICD-10 was to improve clinical communication due to the enhanced standardization of medical codes (source). Where the old ICD-9 codes only held 18,00 codes, the new ICD-10 codes now held 155,00 codes (International Classification of Diseases, 2011). It was evident that a new system was necessary and this was the next step in streamlining the goals of Healthcare Reform. This nation-wide, multibillion dollar change effort shook up the entire Healthcare industry as a whole and intended to produced transformational change
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
Introduction & Summary Clinical Decision Support systems are systems that aid in the provision of person-specific information and knowledge to patients, medical practitioners, clinicians and other persons within a health care setting. This person-specific information is presented and filtered according to the requirements in order to assist in enhancing the health care services and the general health of the patient. CDS system is comprised of a variety of tools including computerized reminders and alerts to healthcare practitioners and patients; focused summaries and reports of patient data; diagnostic support; order sets that are condition-specific; reference information with contextual relevance and documentation templates (Health IT 2013).
Documentation is a form of communication that provides information about the patient and confirms that care was provided to that patient. Some reasons why nurses document is for communication and continuity of care of the patient and by that it means clear, complete and accurate documentation in a health record ensures that all those involved in a client’s care, including the client, have access to information upon which to plan and evaluate their interventions. Next, quality improvement/assurance and risk management through chart audits and performance reviews documentation is used to evaluate quality of services and appropriateness of care. Additional reason is it establishes professional accountability because documenting that is showing a valuable method of demonstrating that nursing knowledge, judgment and skills have been applied within a nurse-client relationship in accordance with the Standards of Practice for Registered Nurses. Another purpose is for legal reasons the client’s record is a legal document and can be used as evidence in a court of law or in a professional conduct proceeding. Courts may use the health record to reconstruct events, establish time and dates, and refresh one’s memory and to substantiate and/or resolve conflicts in testimony. Although you may never be named as a defendant in legal case, you may be called to testify at a discovery or