Question

Clinical Documentation Improvement (HIM Assignment)

*What steps would you as the HIM Director do to improve documentation?

* Who would you involve in the documentation improvement program, including physicians or other providers?

* Describe each of the above issues in relation to a patient medical record.

* What type of follow-up would be needed to ensure the documentation improvement program is working? When would you do this, how often?

Answer 1

*Some of the steps which could be taken by HIM Director to improve the quality of documentation are

• To oversee the work done by the physician, nurses,case manager, chief financial officers and other healthcare professional for their documentation
• To implement process and system to improve the documentation method by providing accurate medical records
• Overseeing the work of coders and making reimbursement easy
• collaborating with the physician to improve documentation
• Staffs having a thorough knowledge on ICD10 and EHR
• Analysis of clinical data for process improvement

*The physician are the most important person to be involved in documentation improvement because they are the one who directly works with the patients and make records by documentations. The other persons like Health Information Technology staffs can be involved to maintain accuracy and secrecy in the documentation

*When it comes to patient medical records the security and privacy forms a major concern so this has to be addressed by proper cyber security system .This helping in maintaining digital and traditional documentation of medical information

*Some of the follow-up needed to ensure the documentation improvement are

• Periodical monitoring of the documentation at least weekly once in the beginning later once in a month
• Daily report can be received from the Incharge of each department
• Conducting basic knowledge assessment on documentation  
• Employees evaluation can be done once a month