CLINICAL DOCUMENTATION: INTEGRITY AND QUALITY

Clinical Documentation In-Service Training Part 4: Discussion Course, Program, and Institutional Outcome(s) Assessed: This assignment measures your ability to meet the following outcome(s): • Course outcome: Explain how document review processes can improve quality and increase reimbursements • Course outcome: Analyze the importance of risk management and quality assurance in clinical documentation • Program outcome: Evaluate the accuracy and completeness of the patient record as defined by policy, external regulations, and standards • Institutional outcome - Community & Career: Participate in social, academic, and professional communities for individual growth and to function as a citizen of a multicultural world Relevant Background Information: Every health care worker who touches patient documentation, from the physician to the medical receptionist, impacts the accuracy of the health record. It is vital that all health care employees understand risk management and quality assurance to ensure that patient records are complete and accurate and to limit the risk of lost reimbursement. Assessment Purpose: To demonstrate an understanding of the importance of quality documentation and the role risk management and quality assurance play in reimbursement. Assessment Directions: Now that you have completed your presentation (attached powerpoint) Follow the steps below to complete this assignment: a. A two paragraph (200-450 word) written summary of your presentation, in which you refer to specific sources in your post. (These will include the three provided articles and other articles included in your presentation.) Source :“Guidelines for Physician Office Query Practices,” which explains the role of CDI and education in physician offices, the query process, and processes to lead to improved documentation. This article can be found in Blackboard. Source: “Recognizing the Value of Clinical Documentation Improvement,” in which a consultant explains the importance of clinical documentation. The article can be found at this link: https://www.healthcare-informatics.com/article/recognizing-value-clinical-documentation-improvement. Source: "Realizing the Benefits of Clinical Documentation Improvement," which discusses how to successfully implement clinical documentation improvement projects. The article can be found at this link: https://ehrintelligence.com/news/realizing-the-benefits-clinical-documentation-improvement. Identifying information for the source(s) you found for this assignment (either a link to the website, the title and publication information of a book or print article, or the article identification from the Virtual Library)                                                                                                                  

Sample Solution