Are you looking for read ebook online? Search for your book and save it on your Kindle device, PC, phones or tablets. Download Clinical Documentation Improvement For Outpatient Care PDF full book. Access full book title Clinical Documentation Improvement For Outpatient Care.
| Author | : Pamela Carroll Hess |
| Publisher | : |
| Total Pages | : 394 |
| Release | : 2018 |
| Genre | : Medical history taking |
| ISBN | : 9781584265849 |
Clinical Documentation Improvement for Outpatient Care: Design and Implementation is an all-inclusive guide to establishing and enhancing CDI programs for the outpatient amd professional fee setting.
| Author | : Heather Taillon |
| Publisher | : HC Pro, Inc. |
| Total Pages | : 171 |
| Release | : 2011-01-21 |
| Genre | : Medical |
| ISBN | : 1601467753 |
The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards
| Author | : Ruthann Russo |
| Publisher | : |
| Total Pages | : 206 |
| Release | : 2003-07-18 |
| Genre | : Medical |
| ISBN | : 9781578393046 |
| Author | : AAPC |
| Publisher | : AAPC |
| Total Pages | : 13 |
| Release | : 2020-03-12 |
| Genre | : Medical |
| ISBN | : 1626889791 |
It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.
| Author | : VIRUTI SHIVAN |
| Publisher | : Viruti Satyan Shivan |
| Total Pages | : 232 |
| Release | : |
| Genre | : Medical |
| ISBN | : |
Dive into the essential world of clinical documentation with "Clinical Documentation Specialist - The Comprehensive Guide," a pivotal resource designed for healthcare professionals committed to excellence in patient care through meticulous record-keeping. This guide offers a deep dive into the principles of accurate and compliant medical documentation, highlighting its critical role in ensuring optimal patient outcomes and the seamless operation of healthcare systems. With an emphasis on practical strategies, real-world applications, and the latest compliance standards, this book serves as an invaluable tool for both aspiring and experienced clinical documentation specialists. By focusing on enhancing communication between healthcare providers and supporting the delivery of high-quality care, it addresses the challenges and complexities of modern medical documentation practices. Without relying on images or illustrations for clarity, the guide stands out for its comprehensive coverage and insightful analysis, making it a unique addition to the professional library of healthcare providers. It transcends basic instructional material by weaving in theoretical knowledge with actionable advice, empowering readers to navigate the nuanced landscape of healthcare documentation with confidence. The absence of visual elements is more than compensated for by the depth of knowledge and the engaging writing style, ensuring that readers are equipped with the knowledge and skills necessary to make a significant impact in their roles as guardians of patient information and care continuity.
| Author | : Anny Pang Yuen |
| Publisher | : |
| Total Pages | : 134 |
| Release | : 2017-06-22 |
| Genre | : |
| ISBN | : 9781683081098 |
First Steps in Outpatient CDI: Tips and Tools for Building a Program Anny P. Yuen, RHIA, CCS, CCDS, CDIP Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO Find best practices and helpful advice for getting started in outpatient CDI with First Steps in Outpatient CDI: Tips and Tools for Building a Program. This first-of-its-kind book provides an overview of what outpatient CDI entails, covers industry guidance and standards for outpatient documentation, reviews the duties of outpatient CDI specialists, and examines how to obtain backing from leadership. Accurate documentation is important not just for code assignment, but also for a variety of quality and reimbursement concerns. In the past decade, outpatient visits increased by 44% while hospital visits decreased by nearly 20%, according to the Medicare Payment Advisory Commission. However, just because physicians are outside the hospital walls doesn't mean they're free from documentation challenges. For these reasons, CDI programs are offering their assistance to physician practices, ambulatory surgical centers, and even emergency rooms. This book will explore those opportunities and take a look at how others are expanding their record review efforts in the outpatient world. This book will help you: Target the outpatient settings that offer the greatest CDI opportunities Understand the quality and payment initiatives affecting outpatient services Understand the coding differences between inpatient and outpatient settings Identify data targets Incorporate physician needs to ensure support for program expansion Assess needs by program type
| Author | : Alyson D. Raines |
| Publisher | : |
| Total Pages | : 100 |
| Release | : 2006 |
| Genre | : Hospital records |
| ISBN | : |
Abstract: A medical record is generated on every patient treated in an inpatient hospital or outpatient facility such as a physician office or ambulatory care center. Information within the medical record is the primary source for determining the care a patient receives and it is the primary source of information used to determine reimbursement for care. In order for documentation to accurately reflect the condition and treatment rendered to a patient medical record documentation by healthcare providers must be timely, specific and complete. The issue of documentation is a problem in the healthcare industry. If a facility's data is not accurate, consistent and reliable; the facility is at a risk of collecting inaccurate data, which diminishes the acuity level of the patients they treat, and provides an inaccurate risk profile. As healthcare organizations recognize the importance of clinical documentation, Clinical Documentation Enhancement Programs must be evaluated to measure their impact within a healthcare facility. The major objective of the CDEP was to promote complete and accurate medical record documentation of patient care. Thus, purpose of this study was to determine whether the Documentation Enhancement Program in an academic medical center was accomplishing the program's goals.
| Author | : Laurie L. Prescott |
| Publisher | : |
| Total Pages | : 0 |
| Release | : 2014-10-23 |
| Genre | : Clinical medicine |
| ISBN | : 9781556452833 |
Your new CDI specialist starts in a few weeks. They have the right background to do the job, but need orientation, training, and help understanding the core skills every new CDI needs. Don't spend time creating training materials from scratch. ACDIS' acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist's Complete Training Guide to serve as a bridge between your new CDI specialists' first day on the job and their first effective steps reviewing records. The Clinical Documentation Improvement Specialist's Complete Training Guide is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities. It will get your staff trained faster and working quicker. This training guide provides: An introduction for managers, with suggestions for training staff and guidance for manual use Sample training timelines Test-your-knowledge questions to reinforce key concepts Case study examples to illustrate essential CDI elements Documentation challenges associated with common diagnoses such as sepsis, pneumonia, and COPD Sample policies and procedures
| Author | : Trey La Charité |
| Publisher | : |
| Total Pages | : |
| Release | : 2014 |
| Genre | : Diagnosis related groups |
| ISBN | : 9781556451638 |
| Author | : Elizabeth I Gonzalez, RN, Bs |
| Publisher | : Hcpro, a Division of Simplify Compliance |
| Total Pages | : 0 |
| Release | : 2014-11-26 |
| Genre | : |
| ISBN | : 9781556452314 |
Clinical Documentation Strategies for Home HealthElizabeth I. Gonzalez, RN, BSN Are you looking for training assistance to help your homecare staff enhance their patient assessment documentation skills? Look no further than Clinical Documentation Strategies for Home Health. This go-to resource features home health clinical documentation strategies to help agencies provide quality patient care and easily achieve regulatory compliance by: Efficiently and effectively training staff to perform proper patient assessment documentation Helping nurses and clinicians understand the importance of accurate documentation to motivate improvement efforts Reducing reimbursement issues and liability risks to address financial and legal concerns This comprehensive resource covers everything homecare providers need to know regarding documentation best practices, including education for staff training, guidance for implementing accurate patient assessment documentation, tips to minimize legal risks, steps to develop foolproof auditing and documentation systems, and assistance with quality assurance and performance improvement (QAPI) management. Clinical Documentation Strategies for Home Health provides: Forms that break down the functions and documentation requirements of the clinical record by Conditions of Participation, Medicare, and PI activities Tips for coding OASIS Examples of legal issues such as negligence Case studies and advice for managing documentation risk (includes a checklist) Comprehensive documentation and auditing tools that can be downloaded and customized Table of Contents: Key aspects of documentation Defensive documentation: Reduce risk and culpability Contemporary nursing practice Clinical documentation Nursing negligence: Understanding your risks and culpability Improving your documentation Developing a foolproof documentation system Auditing your documentation system Telehealth and EHR in homecare Motivating yourself and others to document completely and accurately
