Michelle Knuckles, RHIA is the manager of Inpatient Clinical Documentation Improvement and Coding at the University of Utah Hospital. Clinical Documentation Improvement is the vital process of ensuring that records are complete and accurate. There are many types of problems that can occur in patient records, such as conflicting information, inconsistent diagnoses, vague documentation, or illegible information. The accuracy of severity of illness and risk of mortality are also important factors for a CDI professional and the organization itself. If a record has inaccurate MS-DRGs, CCs, MCCs, APR-DRGs, or mortality index; the hospital is unable to truly participate in hospital compare through Medicare and cannot create an accurate picture of their stance compared to state and national benchmarks. The role of a CDI professional is to catch these problems and assist in resolving them which results in a complete and accurate record at the time of the patient’s discharge. CDI is an important part of a patient’s quality of …show more content…
care because if the patient’s record is inaccurate, the provider cannot make treatment decisions with the best interest of the patient in mind.
Clinical Documentation Improvement also has connections to reimbursement, quality of healthcare, and public reporting; and facilities rely on CDI for all of it.
The process of clinical documentation improvement has a defined list of goals it needs to meet. They are to have accurate Present on Admission documentation, reviews of records going to all payers, accurate public reporting of diseases and illnesses, specific and accurate codes, decrease the volume of third party denials of claims, and reduce risks through recovery audits. CDI professionals also need to be able to work well with people in many different roles as they will work with a variety of departments during their work of ensuring an accurate written
record. For example, CDI professionals often need to communicate with physicians and other providers via queries in order to improve and correct the documentation. These queries are subject to oversight in order to prevent professionals from leading the provider to the right or desired answer rather than letting the provider come to their own conclusion. Coders and registered nurses are also involved as CDI is the bridge between the clinical side and the coding side. During the CDI process, coders will do an initial review of the record and assign a working DRG. Next, coders will work with a registered nurse to create the necessary provider queries. The registered nurse will use his or her clinical knowledge to help to capture all of the queries that need to be sent to the provider. Lastly, a review is done to verify that the clinical indicators match up to the provider’s documentation. Reviews such as these are done throughout the entire stay of a patient, continuing until the patient is discharged from the facility. This concurrent review will fix documentation as it is created and as the patient is treated. The alternative is to wait until after the patient is discharged from the facility to do a retrospective review which would be more time consuming and potentially result in less accurate information from the providers. There are reimbursement consequences to maintaining an inaccurate medical record. Details as small as one incorrect digit on an address to surgeries being billed to the payer that the patient did not have, will always cause reimbursement problems. Healthcare facilities can experience claim denials, delayed payments, breaches of contracts, and even fines for maintaining incomplete and inaccurate documentation. The potential reimbursement consequences as well as consequences to the patient’s quality of care, the importance of clinical documentation is immense to a healthcare facility. CDI has an impact on virtually everything, from patient care to billing, from statistics to public reporting, there will always be a need for clinical documentation in healthcare.
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.
The Beginning Stages of the Writing and Publication Process: Matching the Topic to the Journal
To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible.
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,
At the end of the day, physicians routinely record their patient notes into a tape recorder or other recording device, depositing the resulting medium at the hospital's transcription department. Since most in-house records departments are not 24/7 operations, there is no action on the patient data until the next morning, when the transcription staff types up the information in the tapes. When the transcription is complete, the st...
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...
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
Improvement in quality of healthcare: Work in interprofessional teams, employ evidence-based practice, utilize informatics, provide patient-centered care, and apply quality improvement (QI).
Language can be an example of poor documentation practices in patient records because it has to be specific, objective, and factual. An example would be a nurse documenting about a patient “appearing to be looking good” the nurse was using vague words and speculating. There needs to be specific facts that the patient is doing well by documenting the patient’s temperature or the reaction to the medication taking affect. Vague words can cause problems to the healthcare provider because the nurse didn’t describe facts and the provider needs facts to prove that the patient is doing well and not send them home still feeling ill. This could cause problems with the patient because the patient may be feeling the opposite and feel ill instead of good.
...to eliminate healthcare system--based errors through centralized records and other streamlining methods to improve processes. In doing so, it seems likely that our patients will gain confidence in us and our ability to help them navigate a complex and confusing system" (Science Daily 2007, 17)
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.
The process of eliminating coding errors can be very tedious and stressful for medical office managers. Training and more training with appropriate supervision. Managers in coding departments must be proactive in ensuring that employees are properly trained and consistently monitor coding practices for accuracy. In addition, "comparative data is available for all types of facilities to compare their data DRG, APC, or other payment
Patient Check-in: This is the 1st step of the appointment and where the flow begins. The patient arrives to the doctor’s office and signs in on the “check in” clip board, most doctor’s office has one in the front desk. Usually it will ask for some basic information so the person on the desk can verify all information in the system is correct.
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