Time Out: Documentation Counts

Authors

Kathleen Shindle, RN, BSN, CCDS, Clinical Documentation Supervisor, Thomas Jefferson University HospitalFollow

Document Type

Presentation

Publication Date

4-16-2015

Abstract

Goals and Objectives of Clinical Documentation Improvement Program:

• Purpose: Concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation.
• Identify documentation opportunities and collaborate with both clinical and coding staff to improve the accuracy of coded diagnoses and procedures representing the patient's episode of care
• Documentation nurse should serve as a resource to the clinical team-serving as a liaison between the clinical and coding staff

A precise medical record:

• Captures the clinical severity of a patient's condition
• Impacts quality metrics and reimbursement
• Validates justification for the expenditure of hospital resources

Presentation: 16 minutes

Recommended Citation

Shindle, RN, BSN, CCDS, Kathleen, "Time Out: Documentation Counts" (2015). Department of Surgery Presentations and Grand Rounds. Presentation 37.
https://jdc.jefferson.edu/surgerygr/37