PPT-Chapter 3 Systems Documentation Techniques

Copyright 2012 Pearson Education Inc publishing as Prentice Hall 3 1 Learning Objectives Prepare and use data flow diagrams to understand evaluate and document information systems Prepare and use flowcharts to understand evaluate and document information systems. And 57375en 57375ere Were None meets the standard for Range of Reading and Level of Text Complexity for grade 8 Its structure pacing and universal appeal make it an appropriate reading choice for reluctant readers 57375e book also o57373ers students 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. Data Dictionaries. 1. Prerequisites. Recommended modules to complete before viewing this module. 1. Introduction to the NLTS2 Training Modules. 2. NLTS2 Study Overview. 3. NLTS2 Study Design and Sampling. 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. For Charter Educators . Sara . Hardner. Leon. Powell & Leon, LLP. Austin, Texas. The Objectives of Effective Documentation. The primary objective for creating effective employee documentation is to:. 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 . Documentation tells a story. Quality documentation tells a story that everyone can understand. What does your documentation say about you? . Financial implications. Documentation is a receipt, warranty and guarantee for payments received.. 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. 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. . ICD-. 10. . State. a. cuity. type . Acute . Chronic. Classification. . Paroxysmal. Persistent. Chronic or permanent . 4/16/14cditipsheet. Most important documentation requirement . for diagnoses. 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. 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 . ICD-10 Procedure Codes = 71,000 . 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. Graphic Documentation Systems in Mural painting Conservation (GraDoc) in November 1999. Published proceedings of this seminar became a widely accepted document addressing purposes, requirements, and m