PPT-Effectiveness in Clinical Documentation

Effectiveness in Clinical Documentation ICD10 Around the Corner Practical Steps for Physician Preparation 1 Objectives Understand and appreciate the underpinnings of the ICD10 system Compare and contrast structural differences between ICD9 and ICD10. Day, Egusquiza, President. AR Systems, Inc . Lori Rathbun, VP Finance. Mercy Network, IA. . 1. Why have Clinical Documentation Improvement?. A consistent ‘set of eyes’ on the record . Concurrent review, with direct feedback-fragmented. . Lighthouse Development Team. Opportunities. Most hospitalized patients with cardiac arrest have. . abnormal physiological values recorded in the hours preceding. . the event. A patient’s baseline condition begins to deteriorate a mean of 6.5 hours before an unexpected critical event or actual cardiac arrest . Laura Triplett, Director, HIM. Roseann Kilby, Clinical Informatics Analyst. Becky Crane, Clinical Risk Manager. 367 Bed Community Health System in Quincy, Illinois . 2,000 Employees. 240+ Physicians. Henry Glick. University of Pennsylvania. www.uphs.upenn.edu/dgimhsr. Cost-Effectiveness Analysis for Clinical Trials. Society for Clinical Trials. Montreal, Canada. 05/15/16. Outline. (Very) Brief introduction to economic evaluation. RCPA Conference. October 8, 2014. Agenda . Behavioral Health Services Cultural Overview. Current Regulatory Environment – New Compliance Challenges. Function of the Progress Note. Defensive Maneuvers – Audit Proof Documentation. Physician Program Overview. Our CDI program works to ensure the documentation in the medical record captures the true acuity of our patients. Accurate documentation will reflect appropriate severity of illness and risk of mortality to support resource intensity and length of stay for our patients. . Adherence to clinical practice guidelines (CPGs) is key to quality of care delivery. . Evidence-based practices for rational antibiotic use are difficult to monitor in private primary healthcare facilities in LMIC settings. . Hospitalist . Presentation . 10/18/10. What is CDI?. BRIDGING THE GAP . Between what CMS (Center for Medicare & Medicaid Services) recognizes (technical terminology of the ICD-9 system) and the clinical language physicians use to describe the patient’s condition. August. 2018. Scribing could slow physician burnout and improve efficiency . Solution. Scribing technologies . consistently report an average of . ~50% savings on time spent . on documentation, freeing up . Geoffrey M. Curran, PhD. Director, Center for Implementation Research. Professor, Departments of Pharmacy Practice and Psychiatry. University of Arkansas for Medical Sciences. Research Health Scientist, Central Arkansas Veterans Healthcare Syste. V 3 Approved by Executive Committee of the Medical Staff on 10 / 19 / 2021 ● Perform clinical assessment to identify source and extent of infection ● Obtain Infectious Diseases ( ID ) consu Mary Kouvas – Clinical Documentation Integrity Coordinator/Health Information Manager. 28. th. January 2021. Learning Objectives. Understand why accurate medical documentation is part of a good medical practice.. Day, Egusquiza, President. AR Systems, Inc . 1. What does “Integrated CDI’ mean- 2 step?. Patient status /UR. coming together with . traditional CDI/coding . to create a coordinated, cohesive effort to ensure documentation in the medical record to support BOTH inpt status or observation PLUS the most complete diagnosis to support correct coding and ICD -10.. Section 4.9.0. “The investigator should maintain adequate and accurate source documents and trial records that include all pertinent observations on each of the site’s trial subjects. Source data should be attributable, legible, contemporaneous, original, accurate, and complete. Changes to source data should be traceable, should not obscure the original entry, and should be explained if necessary (e.g., via an audit trail).” .