PPT-Systems Documentation Techniques

Chapter 3 31 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. 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.. 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. 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:. 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. 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 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 . 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 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 Nutrition Assessment. May 11, 2021 . Speaker: Luz Hago. Indicators – Medical Documentation. 2017/2018. 2020/2021. MD completed correctly . 61. 62.3. Prescription UpToDate . 93.5. 100. Reason for Issuance.