2.50
Hdl Handle:
http://hdl.handle.net/10755/151570
Type:
Presentation
Title:
Correct Documentation: The Axis
Abstract:
Correct Documentation: The Axis
Conference Sponsor:Sigma Theta Tau International
Conference Year:2006
Author:Brown, Michael, BSN, RN, CCA
P.I. Institution Name:The Methodist Hospital
Title:Cardiology Coder
Documentation of patient care functions much like that of a spoke in a wheel: providing support and a common point of reference for the whole.  Evidence supports that the quality of data recorded is an important as the quality of care given to patients. Correct documentation provides a vital link between caregiver and patient. Correspondingly; the significance of this issue is far reaching. One only has to consider the ramifications that inaccurate or incomplete data could have on financial considerations, legal questions, and patient safety. Study showed that the indications for the procedures and incomplete descriptions of the procedure were common deficiencies found in audited cases.  CMS found that in 2004 payment errors resulted from incomplete documentation of care given and need for medical necessity. Office of Inspector General has focused on accurate, complete, timeliness and ?date and legible identity of the observer,? of the signatures. Consequently, poor documentation can result in inaccurate coding that can affect dollars assigned to DRG?S.  An area of process improvement opportunity was identified in the cardiac catheterization unit to identify baseline procedure documentation accuracy and identify potential revenue loss. Educational in-services, two tools was developed, a double-checking strategy was implemented. After three months of implementing process improvement initiatives, potential revenue loss was decreased from $85,000.00 to $25,000.00. This presentation will show that proper documentation not only impacts the financial health of the organization but most importantly promote patient safety.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleCorrect Documentation: The Axisen_GB
dc.identifier.urihttp://hdl.handle.net/10755/151570-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Correct Documentation: The Axis</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2006</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Brown, Michael, BSN, RN, CCA</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">The Methodist Hospital</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Cardiology Coder</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">mebrown@tmh.tmc.edu</td></tr><tr><td colspan="2" class="item-abstract">Documentation of patient care functions much like that of a spoke in a wheel: providing support and a common point of reference for the whole.&nbsp; Evidence supports that the quality of data recorded is an important as the quality of care given to patients. Correct documentation provides a vital link between caregiver and patient. Correspondingly; the significance of this issue is far reaching. One only has to consider the ramifications that inaccurate or incomplete data could have on financial considerations, legal questions, and patient safety. Study showed that the indications for the procedures and incomplete descriptions of the procedure were common deficiencies found in audited cases.&nbsp; CMS found that in 2004 payment errors resulted from incomplete documentation of care given and need for medical necessity. Office of Inspector General has focused on accurate, complete, timeliness and ?date and legible identity of the observer,? of the signatures. Consequently, poor documentation can result in inaccurate coding that can affect dollars assigned to DRG?S.&nbsp; An area of process improvement opportunity was identified in the cardiac catheterization unit to identify baseline procedure documentation accuracy and identify potential revenue loss. Educational in-services, two tools was developed, a double-checking strategy was implemented. After three months of implementing process improvement initiatives, potential revenue loss was decreased from $85,000.00 to $25,000.00. This presentation will show that proper documentation not only impacts the financial health of the organization but most importantly promote patient safety.</td></tr></table>en_GB
dc.date.available2011-10-26T11:06:37Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T11:06:37Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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