Time Out: Documentation Counts
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 CitationShindle, RN, BSN, CCDS, Kathleen, "Time Out: Documentation Counts" (2015). Department of Surgery, Grand Rounds. Presentation 37.