Question

Section 5 • COMPLIANCE ASE 5-13 Documentation Improvement Laura just finished a documentation audit for the HIM department at the hospital where she works. She not surprised to learn that there were significant documentation problems. The top four problems deres 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 documentation, and medical staff regulations for completion and content • Progress notes are very brief and do not adequately describe the patients improvement or lack there • 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. dentify the follow-up required to ensure that documentation improves. Justify your respo

Answer 1

1.First step toward better clinical documentation is for a practice to create guidelines for note taking that align with industry standards.The American College of Physician(ACP) recently released a report that detailed various ways that medical providers can improve their documentation.The authers stated that practices should define guidelines based on"consensus-driven professional standards unique to individual specialties."

Some practice may assume that new staff members understand documentation standard,but knowledge of these skills can always be improved.The Healthcare Financial Management Association explained that healthcare organizations will benefit from providing structured training on clinical documentation to new and existing employees.

It may seem like a no brainer, but taking a few minutes to review the accuracy of past documentation can be extremely beneficial in improving overall accuracy of EHRs.when physician take time to quickly validate notes with patients,they can catch small errors that may still be on file.

It is inevitable that physician will make documentation mistake from time to time ,and who is better qualified to catch these errors than patients?The ACP report noted that when patients are able to review their medical records,they often find inaccuracies that could be substantial in optimizing treatment.

Nominating a physician leader to spearhead documentation improvrment is often a good way to reduce relience on EHR vendors or third-party trainers.When there is a staff member who knows the ins and outs of best documentation practice,a peer -to- peer support system will be created.

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