Chapter 1 - Purpose of Clinical Documentation Improvement (CDI)

Chapter 1 - Purpose of Clinical Documentation Improvement (CDI) CDI - Clinical Documentation Improvement Reasons For Clinical Documentation Analysis - More patient involvement, increasing regulatory demands, greater use of electronic medical records & more frequent audits CDEO's review clinical documentation in order to - Improve accuracy of clinical documentation when communicating patient care while adhering to regulatory requirements & noting appropriate support services. CDEO Responsibilities - Establish, maintain and monitor policies to reduce risk; develop and monitor internal protocols for staff entering patient data; and perform ongoing reviews for accurate data. CDEO Best Practices - Monitor timeliness of documentation; review and remedy documentation deficiencies by providers; educate and train providers on importance of documenting medical necessity Central focus of clinical documentation? - To facilitate optimum patient care. The CDEO will focus his or her attention on records requested for post payment review. - No, CDEOs review records on a proactive basis to prevent documentation deficiencies. The CDEO will review the findings of the auditor in order to - Prevent deficient documentation Which of the following sources other than federal healthcare plans may request the medical records? - I. Patients II. Providers involved with the patient's care III. Employers for worker's compensation claims IV. Private payers Other than the site of service the medical record may be used to validate: - The appropriateness of the services provided. A provider's best defense in any legal situation is: - Detailed, well documented notes. To maintain an accurate medical record, what is the recommended appropriate time for provider documentation? - During the encounter or as soon as possible. Quality assurance of patient care is only evident if: - If it is documented in the patient's medical record.