Clinical Documentation Matters

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CDMatters | Is Your CDI Program Increasing Compliance Risk Instead of Decreasing It?

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Clinical Documentation Matters

www.ClinicalDocumentationMatters.com

Why Physician Education Will Set You Free
Education will set you free, in all things, including Medicare fraud and abuse investigations. Recently, the Office of the Inspector General (OIG) began investigating possible Medicare billing fraud and abuse from a new perspective. Apparently, some physicians have made contact with the government to complain about the pressure they felt to document in a certain way in medical records at hospitals where they admit patients. Requests were made, said these physicians, by physician leaders in the hospital who asked attending physicians to document a blood loss anemia, dehydration, CHF, or other condition in their patients’ records. In many cases, the attending physicians did not agree with the requests. But, they said, they felt pressured to provide the documentation.
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Webcast: Statement of Physician Rights and Responsibilities
If you are interested in learning more about developing a statement of physician's rights and responsibilities in their clinical documentation for your organization, attend the Webcast on February 18th from 1 PM to 2:30 PM ET.  You will:

  1. Receive a comprehensive PowerPoint presentation on creating a rights and responsibilities Statement
  2. Learn to create a rights and responsibilities statement
  3. Negotiate administrative support for the activity
  4. Discover how to integrate the statement into your CDI program
  5. Obtain sample rights and responsibilities statements for physicians in their clinical documentation
  6. Understand how to use the statement strategically within the organization well into the future

Cost: for this session:
$175 per site (live recording)
$225 per site (live recording + ongoing web-based access)
Register Now

Using Six Sigma Concepts to Clarify Your Approach to CDI
Six Sigma defines a defect as any failure of a product or service to meet customer requirements. The "customer" may be an external consumer, or it may be an internal customer. According to Michael L. George, author of Lean Six Sigma for Service, “work that adds no value in your customers’ eyes typically comprises 50 percent of total service costs.” George further goes on to describe how Stanford Hospital and Clinics was able to improve the quality of patient care and decrease its costs by applying Six Sigma concepts. One of the measures achieved by the Stanford Hospital system was a drop in mortality from coronary artery bypass graft surgery by 48 percent. Some component of this measure was most certainly driven by improvement in clinical documentation.
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Reader Poll
Vistors were asked the following quesion and here are the results

About how many beds does each CDI Specialist manage for your inpatient CDI program?

Less than 50 - 61.5%
60 - 7.7%
75 - 0%
90 - 7.7%
More than 90 - 23.1%

Current Poll
Which title best describes your current job duties?
Vote now at cdmatters.com

Clinical Documentation Matters is a web-based resource and newsletter for clinical documentation professionals…sign up for our complimentary weekly newsletter now.

Did You Know?
In a study published in The Journal of Bone and Joint Surgery, the researchers note that a possible reason for the widespread lack of proper documentation is a lack of emphasis on careful documentation in medical school, residency, and physician practices.

Sample Job Description:
Clinical Documentation Manager

Documentation Example:
Confirmation of Supplemental Physicians’ Notes

CDI-Cast, New From Dr. Ruthann Russo
New CDI-Cast training sessions consist of 12 one-hour audio sessions, delivered on demand via the Internet with accompanying slides and resources available for download.
More Info | Order Now

Sources for Clinical Documentation Guidance

Sample Physician Query Procedure

The Seven Criteria for High Quality Clinical Documentation

For more information
please visit http://www.cdmatters.com

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