Encourage the provider to a specific diagnosis or procedure. Even one or two lines from the provider add detail and integrity to the note by answering all-important questions such as “How is this note unique?” or “What is unique to this patient at this visit?”. There are many tools and publications to assist providers in improving their clinical documentation such as AAPC’s auditing software and services and Healthicity Healthcare Auditing Services. Conduct periodic documentation reviews, making sure everyone in the practice understands this is being done to identify knowledge gaps, not to punish individuals. 3. Similarly, if aspects of a patient’s medical history play a role in the physician’s decision-making, a summary of that history and how it affects treatment options should be included. Collaborate efficiently: Ideally, each provider or specialist should provide an interval or pertinent history as it pertains to the portion of care they are providing. Then, paste the image into a word processing program and send it as a file attachment to the intended recepient. Unlike a traditional clinical documentation improvement specialist, the documentation quality manager is responsible for improving the technical component of documentation and coding. December 2020 7 . We provide screenshots of our toolkits, details of data fields collected, and diagnoses of patients at the initial visit. Lippincott DocuCare enhances clinical learning by contextualizing realistic patient care scenarios with hands-on documentation. This program is designed to provide a true representation of the impact clinical documentation Quite often historical clinical information is “pulled forward” to the current encounter, and the conditions present at the initial onset of the patient’s presentation to the facility no longer exist, yet the conditions or diagnoses remain in the active problem list. Its intuitive educational experience lets you interact with your students, track their progress, and focus your teaching strategies using evaluation tools, pre-populated cases, and a unified simulation experience. The most important step to clinical documentation improvement is to create guidelines that match the best practices and industry standards. Unless the care is maintenance or supportive care, develop an individual treatment plan for each patient. According to the American College of Physicians, practices should define guidelines based on “consensus-driven professional standards unique to individual specialties.”. For example, if the physician must consider co-morbidities when deciding a course of treatment, the existence and status of those co-morbidities should be noted in the documentation. Clinical Documentation Improvement (CDI) Basics You can make a copy of your quiz result and email it to a recipient by pressing the Alt and PrtScr buttons at the same time while viewing your score. Best practices require that a CDI physician advisor, often a hospitalist, support the CDI program. It isn’t advisable for all collaborating clinicians to copy/paste the history, lab, and testing results from before because it makes it difficult for a reader (i.e., fellow clinician, auditor, or coder) to determine the current nature of the condition being treated versus repeat clinical care. The primary evidence is the Form CMS-2567, and any other documentation used to make the determination of survey results (e.g., surveyor notes). In the facility setting, collaboration is both more readily available and vital to ongoing success. Best Practices in the Art and Science of Clinical Documentation Improvement. In summary, a clinical documentation improvement program is a comprehensive, multi-disciplinary effort that includes the medical staff, clinical documentation specialists, inpatient coders, and CDI physician advisors. Constant and regular training will definitely improve the skill level of your staff in not just documentation but also in identification and rectification of problems. Astara N. Crews, MJ, BS, CHC, CPC, has over 20 years of experience in coding, auditing, compliance, and corporate governance. Improve documentation by introducing best practices that reduce incomplete and lack of specificity in documentation; Lower clinical denial rates by providing ample clinical documentation to support diagnosis and withstand third party denial; Provide focused physician education by providing data showing specific trends Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best can we maximize the integrity of the medical record?” Although the goal of CDI is always the same — to provide a complete and accurate picture of a patient’s medical condition(s) and the care they receive — the means to achieve that goal are often specific to the setting (e.g., office versus facility). Insights and Best Practices for Clinical Documentation Improvement Programs In the face of alarming predictions about ICD-10’s administrative impact and its veritable explosion of new codes to wrangle with, and despite the proven positive impact on improving the accuracy of DRG assignment and quality metrics, some hospitals still We are looking for thought leaders to contribute content to AAPC’s Knowledge Center. The ultimate provider documentation goal is not just about reimbursement, but ideally should recognize coding requirements and capture the relevant details to meet those requirements. Training should be an ongoing process as there are constant upgrades and improvements to EHR software, changes in regulations and the requirements of payers. By encouraging discussion and active learning, this interactive event prepares ... • Clinical Documentation Improvement: Quality Measures and Tailor documentation to capture clinical aspects and contributions, as well as,! 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