Introduction The Clinical Documentation Improvement (CDI) program has continued to provide a pathway for improving Physician’s clinical documentation. This requires a collaborative effort from the Health Information Management (HIM) professionals to assist the Physicians in maintaining a sound health record to enhance clinical clarity. From the onset, the use of CDI program has continued to thrive in all healthcare settings across the United States (especially in the hospitals) as a holistic approach to promote effective data quality reporting. Expanding the CDI initiative into ambulatory and outpatient settings have become an increased focus for the CDI specialist to ensure a smooth data reporting. Beyond these measures, many private …show more content…
Thus, to address the Physicians about the CDI program, I will need to know the audience I will be working with whether they are mid-level Physicians or academic physicians and approached each differently with the intent to acquire sufficient information about their understanding of clinical documentation improvement and Physician query process. I will then work with them to determine the area of where maintaining a sound health record is lacking as well as to identify gaps in their knowledge about CDI programs. In addition, the Physicians will be assessed to find out what they know about clinical documentation improvement using questionnaires. Departmental meetings will be conducted on a regular basis to inform the Physicians the goal of conducting queries to ensure clarity, consistency and completeness of patients’ medical health record. A face-to-face interview will also be conducted with the pool of practicing Physicians to determine their readiness for change. In addition, I will review the Physician’s understanding of the American health information management (AHIMA) guidelines for clinical documentation improvement (CDI) which will be carried out during the face-to-face interview to ensure they are onboard with the organization’s strategic goal on maintaining a complete health record. The Physicians’ will also be provided with training and education on CDI program that includes information on why queries are being utilized across the hospital to help overcome their fears of maintaining a sound and complete health records. According to Rosenbaum et al. (2013), educating the Physicians is a significant step for a hospital “to enhance and ensure useful and appropriate documentation of the medically indicated care that is delivered”
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.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
The preliminary effects of the Meaningful Use Program have began to have an impact on improving the quality of care and its’ safety and efficiency. I gained a greater understanding of information technology and it’s role and importance to my current and future practice. I learned the goal of the Meaningful Use Program isn’t just to install technology in facilities across the nation its so much more. The goals are to empower patients and their families, reduce health disparities and support research and health data. The EHR can prevent medication errors, reduce long term medical costs, improve population health and through the Meaningful use program the vision of this program is becoming reality.
...f clinical information systems in health care quality improvement. The Health Care Manager. 25(3): 206-212.
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
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.
There are several possible methods of addressing the healthcare concerns of today. I focused on three ways to address this issue. The first would it be to make electronic records universal. Secondly, focus on patient centered care. Lastly, start healthcare groups throughout the practice of medicine.
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
Chun-Ju Hsiao, P. a. (2014, January 17). Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. Retrieved April 24, 2014, from CDC: http://www.cdc.gov/nchs/data/databriefs/db143.htm
Nursing documentation is an important factor of healthcare delivery today. The use of information and communication technology offers opportunities for improving patient care delivery while reducing nurses’ documentation load and increasing the time available for caring for various patient populations (Munyisia, Yu, & Hailey, 2012).
Encinosa, W. E., & Jaeyong, B. (2013). Will Meaningful Use Electronic Medical Records Reduce Hospital Costs?. American Journal Of Managed Care, 19eSP19-eSP25.
The American Health Information Management Association is a body of health information professionals that majorly concerns itself with the improvement of the quality of medical records (Harman 104). These health data records are vital for the purposes of monitoring the progress of patients, performance improvements and for improving outcomes.
Journal Title: Impact of Health Information Technology on the Quality of Patient Care. Introduction: Our clinical knowledge is expanding. The researchers have first proposed the concept of electronic health records (EHR) to gather and analyze every clinical outcome. By the late 1990s, computer-based patient records (CPR) were replaced with the term EHR (Wager et al., 2009).