Question

Please help!

DOCOMENTATION IMPROVEMENT:  Laura just finished a documentation audit for the HIM department at the hospital where she works. She was not surprised to learn that there were significant documentation problems. The top four problems identified were the following:

-History and physicals (H&Ps) do not meet medical staff bylaws for time of completion and content.

-Discharge summaries do not meet Joint Commission, Centers for Medicare and Medicaid guidelines for documentation and medical staff regulations for completion and content.

-Progress notes are very brief and do not adequately describe the patient’s improvement or lack thereof

-The diagnoses do not provide specificity

Now that the problems have been identified, she has to come up with the solutions and their implementation.

1. Recommend steps to improve documentation:

2. Identify who should be involved in this documentation improvement program.

3. Identify any additional information that you would like to know. Justify your response.

4. Explain the problems that these deficiencies may cause a healthcare organization.

Answer 1

Documentation process is a vital aspect in the health care management.The proper documentation process will ensure the proper recording of the medical information thus ensure a quality patient care.

1.While during the process of documentation it should maintain accuracy,specificity and completeness thus can offer a quality care to the patient.

*while during the process of documentation it should include the completeness of specific activity done

*Should maintain a specific standard while during the documantation of medical information

*While documenting the medical information it should maintain the clarity,and the needs of other readers to be consider

*Create a specific guidelines or criteria regarding the process of documentation from the part of organization with in the professional context can improve the standards of documentation thus to minimize the errors

*The progress should be adequate regarding the patient physical examination,diagnoses treatment and procedures and improvement in patient condition

*The proper documentation will helpful for the billing and coding of particular diseases,diagnosis and procedures done

*Thus proper coding will ensure the claiming of health plans for the particular condition

*A good dischrge summary should contain each and every activities done to the patient from the time of admission till discharge

*The information provided in the discharge summary is in chronological manner and should not use any abbrevations or acronyms

*The discharge summary will provide accurate information regarding the medical advice to be carried after discharge or in home

*The discharge summary has to point out the need for follow-ups

2.A clinical document specialistis needed in the hospital

*The clinical document specialist,who review the clinical documents regularly and provide feedback to the physicians

*If needed provide education to the new and existing employees through a structured training on clinical documentation

3.A good peer-review system or peer-to-peer support system should be implemented

*Through the peer review system each one of the staff should be curious to keep up with the new developments or trends to improve their skills in the process of documentation

*If any of the staff knows the recent advancements in clinical documentation,through the peer-review system it will generalize to other staff.

*If some one has occured any faults in the documentation process the peer-review support system will support the staff to correct their particular faults thus to minimize the errors in the process of documentation

4.

*Improper documentation will leads to inaccurate quality and care information

*Inadequate to know the patient prognosis

*Lose the name and fame of the organization among the public

*Some times the improper documentation will results harm to the patient as a criminal offence results in losing of license

*Reflects the poor clinical care that results in compromise condition of the patient

*It reflects the gaps among the patient care provided

*Results in inappropriate billing that leads to extra burden to the patient will consider as a fraud action from the organization