PPT-Optimizing Clinical Documentation Efficiency

How to Get Home on Time for Dinner Wayne Kaniewski MD RECENT HISTORY HITECH Act of 2009 Clinicians given 5 years to implement Meaningful Use EHRs High stress High expense Partly our fault. 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 . ethical, legal and clinical issues. Margaret . BROWN. Research . Fellow, Hawke Research Institute, University of South . Australia. Ravi RUBERU. Geriatric . Registrar, Royal Adelaide . 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. 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 . 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).” . CEDM CEIC Seminar. Jennie Chen, WRI, . ReGrid. May 4, 2022. Abstract. The U.S. is about to ramp up electric transmission buildout, and that's good news generally for clean energy. However, the way we plan transmission in relation to generation and...