Title

Time Out: Documentation Counts

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

Share

COinS