PPT-OB Physician Documentation

End User Education Agenda Brief Intro to Physician Documentation PDOC FeaturesBenefits Review list of OB Documents How to Document in PDOC Signing Workflow Resident to Attending Medical Student to Resident to Attending. 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. 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. For Medicare Enrollees. Helping patients succeed at home with home health care is a rewarding aspect of medical practice that promotes independence, keeps families intact, and provides value. The Affordable Care Act has changed the physician home health initial certification requirements for Medicare beneficiaries effective 4/1/2011 to include a face-to-face encounters . 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). EMS Documentation Uses. Legal record. Continuity of care with hospital. Internal quality assurance. Billing record. Today’s Environment. Government focus on fraud. Increased audits. Legally collecting every dollar . 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:. 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.. Certified Clinical Documentation Specialist. Physician CDI Preparation for ICD-10. Clinical Documentation Integrity Program:. “. We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”. to Provider Engagement . Karen DiMeglio, RN, MS, CPC, CCDS. Director of CDI and Appeals. Lifespan. Jill O’Brien, MD, CHCQM. Medical Director of Case Management. Physician Advisor CDI/Coding. The Miriam Hospital . A Physician Perspective. Dr. Susan Kohl. Medical Director CDI. Baylor University Medical Center. Dallas, Texas. Dr. Susan Kohl. After growing up in Austin, Texas, Susan Kohl graduated with honors from the University of Texas at Austin. She graduated from medical school at the University of Texas Southwestern Medical School in 1991, followed by an internal medicine internship at the University of Colorado School of Medicine. She returned to Dallas to complete her internal medicine residency at UT Southwestern. . Emerging CDI Trends in 2015: CDI Survey Findings and Tips to Elevate Physician Engagement John Zelem, MD, FACS, Vice President, Clinical & Regulatory Learning Objectives What are documentation basics for physicians? 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 . 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..