Other request than Federal Healthplans - For different reasons other than reimbursement,
requests for medical records come from different sources, for a multitude of different reasons. A few of
these, other than Federal Health Care Plans, are patients who are becoming more active in their care ,
...
Other request than Federal Healthplans - For different reasons other than reimbursement,
requests for medical records come from different sources, for a multitude of different reasons. A few of
these, other than Federal Health Care Plans, are patients who are becoming more active in their care ,
attorneys seeking information for third party liability claims or mal-practice claims, other providers
involved in the patients' care, employers for pre-employment applications and worker's compensation
cases, private payers, recruiting offices for military applications, and the social security administration for
the patients' SSI applications.
Individuals protected health information - Demographic data, name, address, birth date, and SS
number.
central focus of clinical documentation - should be to demonstrate the quality of care provided to
the patient with detail and accuracy to facilitate optimum patient care.
CDEO Focus - Clinical documentation improvement is a proactive measure. The CDS will develop
and monitor policies and procedures that affect the documentation process. CDI should begin at the
front end of all services and care. Prevention of documentation issues is the key.
CDEO Review - The CDEO will review the findings of the auditor to determine what should be
done to resolve documentation the issues on a proactive basis to prevent documentation and
compliance risks.
The appropriateness of the services provided - In addition to facilitating high quality patient care,
a properly documented medical record verifies and documents precisely what services were actually
provided. Other than the site of service the medical record may be used to validate:
HIPPA - Health Insurance Portability and Accountability Act of 1996 and the Healthcare Fraud and
abuse control program. Far-reaching program to combat fraud and abuse in healthcare including both
public and private health plans.
Medical Record Validates - In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what services were actually provided. The
,medical record may be used to validate: (a) The site of the service; (b) The appropriateness of the
services provided; (c) The accuracy of the billing; and (d) The identity of the caregiver.
Detailed, well documented notes - The details in a well-documented note are a provider's best
defense in any legal situation. If the record is deficient in details, there is no "evidence" to support a
provider's testimony.
During the encounter or as soon as possible - To maintain an accurate medical record, what is the
recommended appropriate time for provider documentation?
If it is documented in the patient's medical record - Quality assurance of patient care is only
evident if:
It encourages physician participation. - Why is it important to involve physicians in Clinical
Documentation Improvement (CDI) programs?
Failure to include the instructions for post procedure care and potential complications. - Which of
the following documentation deficiencies has a negative impact on patient outcomes?
Provide examples of the provider's documentation deficiencies with suggestions for improvement. -
What is an effective method for communicating documentation deficiencies to a provider?
Improve patient outcomes, Improve patient outcomes, and improve the provider query process. -
Which of the following is/are considered a purpose of documentation improvement programs?
How can an effective CDI program improve patient outcomes? - The main goal for detailed
medical records is to promote the continuity of care for the patient. This allows providers to
communicate with each other on the care that has been provided to the patient. Coding higher level
services that are not medically necessary is not a goal to improve patient outcomes.
Which of the following recommendations should be made to providers regarding the patient's problem
list? - Problem lists should be updated when a significant change takes place to make sure the
information on the problem list is still current and accurate. A common problem is the list is created but
, it is not maintained so it becomes difficult to know which conditions are current and which are resolved.
If the problem list is maintained, it is an effective tool for managing the patient's conditions.
negative patient outcomes - Failure to document an allergy could lead to an allergic reaction if the
provider prescribes a medication not realizing the patient is allergic.
What is a documentation challenge for services provided by providers in an inpatient facility? -
Documentation deficiencies may not be identified until after the provider has left.
Documentation Challenges - Maintaining consistent and quality documentation can be difficult in
the inpatient setting because deficiencies may not be identified until after the provider has left the
facility.
Quality Care standard - The basic CMS documentation guidelines for E/M services include the
least expected documentation to support an encounter. Quality is going above and beyond the basic
information.
What are some common documentation deficiencies - ommon documentation deficiencies
include: Sloppy text
Misspelled words
Phrases that do not make sense
Dictation that is not complete
Skips in the text that indicate the words were not understoodIncomplete sentences
Evidence of cloning or copying data from previous dates of service that is not relevant to the current
serviceIncorrect dates of service
Missing dates of service
Missing dosage and strength of medication ordered
Missing orders for diagnostic tests
Focus on the highest risk area - For a CDI program to be effective, the CDEO should focus on
correction of documentation deficiencies for identified risk areas specific to the practice.
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