www.ClinicalDocumentationMatters.com Incorporating the 7 Criteria of High Quality Clinical Documentation (HQCD) into Your CDI Program
Every revolution needs a theory. Clinical documentation is no different. The theory of high quality clinical documentation (HQCD) states that if the seven criteria of high quality clinical documentation are applied to clinical documentation, then clinical documentation quality will be high and the accuracy of care, quality indicators, reimbursement, healthcare planning, and research (the activities that clinical documentation impacts) will be improved. The building blocks of clinical documentation quality include the following seven criteria: legible, complete, clear, consistent, precise, reliable, and timely. Listed below are the seven criteria for high quality clinical documentation. 1. Legible
2. Complete
3. Clear
4. Consistent
5. Precise
6. Reliable
7. Timely
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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 Want Feedback on Their Documentation
Research shows that physicians are interested not just in training on documentation, but they desire to apply what they have learned, and they want to receive constructive criticism on their work. When physicians who participated in the CAMP™ Method study were asked, What do you consider to be your strengths when it comes to clinical documentation?, three key phrases were identified:
1. legible handwriting
2. all/differential diagnoses
3. thoroughness
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Reader Poll
Vistors were asked the following quesion and here are the results
My facility has CDI physician trainers on staff. Yes - 22%
No - 75%
Unsure - 2.8%
Current Poll
About how many beds does each CDI Specialist manage for your inpatient CDI program?
Vote now at cdmatters.com
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Timeliness Matters
In a study published in The Journal of Bone and Joint Surgery, the researchers found that the quality of the documentation in the patient’s record was susceptible to neglect and data loss if the documentation was not provided by the physician immediately after the care was given. Sample Job Description:
Clinical Documentation Manager Documentation Example:
Confirmation of Non-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 |
