www.ClinicalDocumentationMatters.com Do Your Physician’s Know their Rights and Responsibilities in their Documentation?
10 Tips to designing a statement of rights and responsibilities for (and with) your medical staff.
Every hospital has expectations about the quality of clinical documentation their physicians will provide in patient records. About 50 percent of hospitals have a clinical documentation improvement (CDI) program in place to bridge the gap between the hospital’s expectations and medical record documentation. While the programs are usually managed by clinical documentation specialists, the ultimate responsibility for documentation rests with the physician. However, physicians do not study principles of clinical documentation during medical school or residency. If they are exposed to documentation training after their formal education, there is no consistency in the information they receive or the way the programs are taught. Moreover, underlying messages delivered to physicians about the importance of documentation for “correct DRG assignment” may leave the physician confused – or worse yet, irritated, about why he needs to modify his documentation practices.
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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: - Receive a comprehensive PowerPoint presentation on creating a rights and responsibilities Statement
- Learn to create a rights and responsibilities statement
- Negotiate administrative support for the activity
- Discover how to integrate the statement into your CDI program
- Obtain sample rights and responsibilities statements for physicians in their clinical documentation
- 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 Physicians Perceive Poor Documentation Practices are Linked to Quality of Care
According to Physicians’ Views on Quality of Care, which reports the results of a survey conducted by The Commonwealth Fund, physicians’ most common problems with quality in healthcare involved health information and lack of coordination of care. An analysis of this information reveals that not only do physicians perceive health information as problematic, they also believe that the improvement would result in higher quality care to patients overall.
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Administrators Should Conduct Patient Rounds
In Strategies for Leadership, the American Hospital Association (AHA) presents a framework to help hospitals learn how to do a better job in talking with patients and families.The AHA suggests that members of the hospital’s management team do patient rounds. The goal of rounds is to find out about patients’ hospital experiences and how well the hospital staff is communicating with them. Although not stated, a secondary goal of administrative patient rounds could be to obtain a better idea of the documentation process. Sample Job Description:
Clinical Documentation Manager Documentation Example:
Consultant's Note 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.
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