PDF-(EBOOK)-Guide to Clinical Documentation

This edition has been completely revised and upgraded with more indepth coverage of documentation and its ramifications more documentation samples to analyze and emulate and even more learning tools You ll also find access to our special version of Amazing Charts online at DavisPlus Amazing Charts is a fully functional Windowsbased professional EMR software package currently being used by more than 3200 medical practices nationwide. 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. 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. . Effectiveness in Clinical Documentation ICD-10 Around the Corner, Practical Steps for Physician Preparation 1 Objectives Understand and appreciate the underpinnings of the ICD-10 system Compare and contrast structural differences between ICD-9 and ICD-10 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. Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, Fourth Edition is ideal for the graduate course on cleft palate and craniofacial conditions, or as a source book for healthcare professionals who provide services in this area. Updated with full color illustrations and photos, the Fourth Edition of this bestselling title has been reorganized to improve clarity and flow, with new references and information reflecting the most current research in the field. Key features such as Case Studies help the learner understand how to apply key information in a clinical setting, while Speech Notes highlight how anomalies and surgeries affect speech and resonance. As the most comprehensive text in the market, Cleft Palate and Craniofacial Conditions answers the questions of \'when, \' \'what, \' \'why, \' and most importantly \'how\' when ensuring evaluation results in an accurate diagnosis. Because the author is both an experienced clinician and instructor, this textbook goes beyond the classroom, serving as a very practical how-to guide as well as a source of didactic and theoretical information. KEY FEATURES New full-color design includes 689 photos and illustrations A complete Glossary of over 650 defined terms Information is summarized in tables for easy learning, including tables of terms for normal and abnormal craniofacial, oral, dental, and pharyngeal structures and anomalies A robust pedagogy includes Chapter Outlines, illustrations, Case Studies, Speech Notes, definitions, and Discussion Questions 295 Clinical Videos illustrate speech samples, evaluation techniques, videofluoroscopy, nasopharyngoscopy, nasometry, and speech therapy techniques, more than any other text in the field! New full-color design includes 689 photos and illustrations A complete Glossary of over 650 defined terms Information is summarized in tables for easy learning, including tables of terms for normal and abnormal craniofacial, oral, dental, and pharyngeal structures and anomalies A robust pedagogy includes Chapter Outlines, illustrations, Case Studies, Speech Notes, definitions, and Discussion Questions 295 Clinical Videos illustrate speech samples, evaluation techniques, videofluoroscopy, nasopharyngoscopy, nasometry, and speech therapy techniques, more than any other text in the field! Dietitian\'s Guide to Assessment and Documentation takes an investigative approach to nutrition assessment - reviewing the collection and analysis of evidence to determine the real nutrition-related problem, understanding the underlying problem and its effect on nutritional status, and providing intervention to address the problem - thereby improving nutritional health. This text will help students learn how to formulate interview questions, how to create goals and patient teaching strategies, how to interpret lab data, how to write a care plan and how to document in a medical record. This book is needed to help the dietitian do a thorough assessment and understand the proper documentation to prevent lawsuit, or defend the dietitian in a lawsuit, as well as prepare the dietitian for Joint Commission or State survey. Includes a reference section for interpretation of lab data and an appendix with commonly used abbreviations. Now in its second edition, The Clinical Documentation Improvement Specialist\'s Guide to ICD-10 is the only guide to address ICD-10 from the CDI point of view. Written by CDI experts and ICD-10 Boot Camp instructors, it explains the ICD-10 documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You\'ll find the specific documentation requirements to appropriately code a variety of conditions. The CDI Specialist\'s Guide to ICD-10, 2nd edition, not only outlines the changes coming in October 2014, it provides detailed information on how to assess staffing needs, training requirements, and implementation strategies. The authors-an ICD-10 certified coder and CDI specialist-collaborated to create a comprehensive selection of ICD-10 sample queries facilities can download and use to jumpstart ICD-10 documentation improvement efforts. Develop the expertise and comfort level you\'ll need to manage this important industry change and help your organization make a smooth transition. The Clinical Documentation Improvement Specialist\'s Guide to ICD- 10, 2nd ed. is part of the library of products and services from the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS members are CDI professionals who share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Member benefits include a quarterly journal, members-only Web site, quarterly networking conference calls, discounts on conferences, and more. WHAT\'S NEW? Completely revised to accommodate changes in ICD-10 implementation dates Dozens of targeted ICD-10 physician queries Updated ICD-10 benchmarking reports BENEFITS Sample ICD-10 queries Specificity requirements and clinical indicators by disease type and body system Staff training and assessment tools This is a student supplement associated with: Health & Physical Assessment in Nursing, 2/e Donita D\'Amico Colleen Barbarito ISBN: 0135114152 Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, Fourth Edition is ideal for the graduate course on cleft palate and craniofacial conditions, or as a source book for healthcare professionals who provide services in this area. Updated with full color illustrations and photos, the Fourth Edition of this bestselling title has been reorganized to improve clarity and flow, with new references and information reflecting the most current research in the field. Key features such as Case Studies help the learner understand how to apply key information in a clinical setting, while Speech Notes highlight how anomalies and surgeries affect speech and resonance. As the most comprehensive text in the market, Cleft Palate and Craniofacial Conditions answers the questions of \'when, \' \'what, \' \'why, \' and most importantly \'how\' when ensuring evaluation results in an accurate diagnosis. Because the author is both an experienced clinician and instructor, this textbook goes beyond the classroom, serving as a very practical how-to guide as well as a source of didactic and theoretical information. KEY FEATURES New full-color design includes 689 photos and illustrations A complete Glossary of over 650 defined terms Information is summarized in tables for easy learning, including tables of terms for normal and abnormal craniofacial, oral, dental, and pharyngeal structures and anomalies A robust pedagogy includes Chapter Outlines, illustrations, Case Studies, Speech Notes, definitions, and Discussion Questions 295 Clinical Videos illustrate speech samples, evaluation techniques, videofluoroscopy, nasopharyngoscopy, nasometry, and speech therapy techniques, more than any other text in the field! New full-color design includes 689 photos and illustrations A complete Glossary of over 650 defined terms Information is summarized in tables for easy learning, including tables of terms for normal and abnormal craniofacial, oral, dental, and pharyngeal structures and anomalies A robust pedagogy includes Chapter Outlines, illustrations, Case Studies, Speech Notes, definitions, and Discussion Questions 295 Clinical Videos illustrate speech samples, evaluation techniques, videofluoroscopy, nasopharyngoscopy, nasometry, and speech therapy techniques, more than any other text in the field! 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..