PPT-Documentation in your 3

rd year and beyond Summer Quarter 2010 Merrian Brooks and Amanda Kocoloski Overview General principles of documentation Types of Notes the case of Ineda Surgery Admission Orders Introduction to hospital charting. 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. 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.. Telana . Fairchild. Nurse Practitioner Students. UMass - Worcester, . Graduate School of Nursing. N/NG . 603B. 1. Narrative. Focused. Flow-sheet. By exception. Problem . oriented. Types of Documentation. 1. Please turn your cell phones off or to vibrate mode.. Welcome to.... ICD-10 Coding. No Recording of ANY TYPE allowed. . Mind expansion in process.... About Dr. Mario Fucinari, DC, CCSP, MCS-P. Certified Chiropractic Sports Physician (CCSP). 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 . 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.. 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. 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. . 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 .