PDF-Technical Report Documentation Page 1 Report No TX0149451 2 Gov

5 Report Date November 2000 4 Title and Subtitle 7 Authors Carol H Walters Valmon J Pezoldt Katie N Womack Scott A Cooner and Beverly T Kuhn 8 Performing Organization Report No Report 4945110. 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. Presenter’s . Name • Date. 2. Introduction. The . goal of . good documentation is to create a record of employment, including facts of incidences and the steps and actions by the employer in an employment matter. Effective documentation serves as an aid to future managers and HR professionals for historical perspective, audits, and legal claims.. Cheryl Bernknopf R.N., BScN. Assistant Director Centauri Summer Camp. Co- Chair OCA Healthcare Committee. Board Member of the ACN. PURPOSE. To provide the multidisciplinary team with a structured note format for documenting. ethical, legal and clinical issues. Margaret . BROWN. Research . Fellow, Hawke Research Institute, University of South . Australia. Ravi RUBERU. Geriatric . Registrar, Royal Adelaide . Dr. Andrew Wallace PhD . BEng. (hons) . EurIng. andrew@cs.umu.se. Overview. Documentation. Javadoc. More documentation. Documentation. Document your program. For others. For yourself. Programs change over time. California Department of Aging. Documentation Rule #1. Documentation. Utilizing the Participant Form Checklist. Official Document or . Business Record. Confirmation of . Signature and Date. Make sure that forms are . Case . Examples & . Highlights. When Documentation Gets in The Way of the Defense. Presented By: . Joanne . Gulliford Hoban. Morrison . Mahoney, LLP. Case #1 – Emergency Department . Example of documentation in ED by both MD & RN. 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. . Jan Malone 8. th. floor Nurse Educator. Importance of Documentation. Helps us track our patient’s progress. Conveys information between disciplines and shifts. Can determine therapy. Is part of the permanent record. 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. . ICD 10 Documentation Specialty Introduction ICD 10 is being mandated by CMS. Compliance date is set at October 2015. ICD-9 Diagnosis Codes = 14,000 ICD-10 Diagnosis Codes = 69,000 ICD-9 Procedure Codes = 3,800 Documentation Log. Assignments Note Taking. http://library.acadiau.ca/sites/default/files/library/tutorials/plagiarism/. http://www.fmtusd.org/Page/8774. http://library.acadiau.ca/sites/default/files/library/tutorials/plagiarism/. ICD-. 10. . State. a. cuity. type . Acute . Chronic. Acute. on chronic . Classification. of respiratory failure . Hypoxemic. Hypercapneic. Both. . 3/1/14cditipsheet. Most important documentation requirement .