Download or read book Guide to Clinical Documentation written by Debra Sullivan and published by F.A. Davis. This book was released on 2011-12-22 with total page 301 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.
Download or read book Successful Collaboration in Healthcare written by Colleen Stukenberg and published by CRC Press. This book was released on 2010-01-27 with total page 138 pages. Available in PDF, EPUB and Kindle. Book excerpt: This critically acclaimed work makes the case for collaboration and shows that it can be greatly enhanced with conscious understanding and systematic effort. As a healthcare specialist who has worn many hats from direct care giver to case manager to documentation specialist, Colleen Stukenberg is able toShow how to build trust and communicat
Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Download or read book Legal Ethical and Practical Aspects of Patient Care Documentation written by Ronald W. Scott and published by Jones & Bartlett Publishers. This book was released on 2013 with total page 296 pages. Available in PDF, EPUB and Kindle. Book excerpt: Fourth Edition, is the only text to integrate coverage of the legal responsibilities of rehabilitation professionals with basic, essential advice on how to effectively document patient care activities from intake through discharge. This resource thoroughly covers the basics of documentation and includes many exemplars, cases, and forms, as well as a sample abbreviations used in rehabilitation settings. This book covers all the bases from ethics, to practical aspects of patient care documentation, to relevant and salient legal implications and illustrative case examples that will help students excel in practice.
Download or read book Unequal Treatment written by Institute of Medicine and published by National Academies Press. This book was released on 2009-02-06 with total page 781 pages. Available in PDF, EPUB and Kindle. Book excerpt: Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received. In Unequal Treatment, a panel of experts documents this evidence and explores how persons of color experience the health care environment. The book examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients' and providers' attitudes, expectations, and behavior are analyzed. How to intervene? Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas. The committee highlights the potential of cross-cultural education to improve provider-patient communication and offers a detailed look at how to integrate cross-cultural learning within the health professions. The book concludes with recommendations for data collection and research initiatives. Unequal Treatment will be vitally important to health care policymakers, administrators, providers, educators, and students as well as advocates for people of color.
Download or read book The Clinical Documentation Improvement Specialist s Handbook Second Edition written by Heather Taillon and published by HC Pro, Inc.. This book was released on 2011-01-21 with total page 171 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards
Download or read book Legal Aspects of Documenting Patient Care written by Ronald W. Scott and published by Jones & Bartlett Learning. This book was released on 2000 with total page 248 pages. Available in PDF, EPUB and Kindle. Book excerpt: This Second Edition Of Our Easy-To-Use Reference Takes A Risk Management Approach To Patient Care Documentation. It Shows Clinicians From A Wide Variety Of Disciplines How To Be Objective, Precise, Unambiguous, And Timely When Documenting Treatment-Related Matters. The Content Is Written In Straightforward Lay Language And Includes Sample Documentation Forms. The New Edition Includes Information On Computerized Documentation; Coverage Of Telehealth Issues; Updates On JCAHO, CARF, And NCQA Accreditation; And Documentation Problems Specific To Non-Hospital And Managed Care Settings.
Download or read book Clinical Documentation Reference Guide First Edition written by AAPC and published by AAPC. This book was released on 2020-03-12 with total page 13 pages. Available in PDF, EPUB and Kindle. Book excerpt: It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.
Download or read book Healthcare Documentation written by Ellen A. Drake and published by Prentice Hall. This book was released on 2014 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Ideal for learners with no prior experience and those seeking refresher training, Healthcare Documentation: Fundamentals and Practice, 4/e is the most comprehensive healthcare documentation learning system available. It begins with a thorough overview of the medicolegal and technology aspects of healthcare documentation, including key trends such as electronic health records, security, privacy, and speech recognition. Next, it provides integrated content linked to 10 hours of authentic medical dictation practice. Extensive exercises in the text combine with online audio exercises to systematically reinforce core knowledge and build critical thinking, editing, and research skills. The final chapter focuses on finding employment and preparing students for the workplace, professional development, and continuing education. This edition has been extensively revised for the latest industry trends and techniques, contains many new learning features, and offers a compelling new full-color design with many new illustrations.
Download or read book Clinical Documentation Specialist The Comprehensive Guide written by VIRUTI SHIVAN and published by Viruti Satyan Shivan. This book was released on with total page 232 pages. Available in PDF, EPUB and Kindle. Book excerpt: Dive into the essential world of clinical documentation with "Clinical Documentation Specialist - The Comprehensive Guide," a pivotal resource designed for healthcare professionals committed to excellence in patient care through meticulous record-keeping. This guide offers a deep dive into the principles of accurate and compliant medical documentation, highlighting its critical role in ensuring optimal patient outcomes and the seamless operation of healthcare systems. With an emphasis on practical strategies, real-world applications, and the latest compliance standards, this book serves as an invaluable tool for both aspiring and experienced clinical documentation specialists. By focusing on enhancing communication between healthcare providers and supporting the delivery of high-quality care, it addresses the challenges and complexities of modern medical documentation practices. Without relying on images or illustrations for clarity, the guide stands out for its comprehensive coverage and insightful analysis, making it a unique addition to the professional library of healthcare providers. It transcends basic instructional material by weaving in theoretical knowledge with actionable advice, empowering readers to navigate the nuanced landscape of healthcare documentation with confidence. The absence of visual elements is more than compensated for by the depth of knowledge and the engaging writing style, ensuring that readers are equipped with the knowledge and skills necessary to make a significant impact in their roles as guardians of patient information and care continuity.
Download or read book Patient Safety and Quality written by Ronda Hughes and published by Department of Health and Human Services. This book was released on 2008 with total page 592 pages. Available in PDF, EPUB and Kindle. Book excerpt: "Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
Download or read book Improving Diagnosis in Health Care written by National Academies of Sciences, Engineering, and Medicine and published by National Academies Press. This book was released on 2015-12-29 with total page 473 pages. Available in PDF, EPUB and Kindle. Book excerpt: Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Download or read book Documentation for Health Records written by Cheryl Gregg Fahrenholz and published by . This book was released on 2017 with total page 488 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Improving Healthcare Quality in Europe Characteristics Effectiveness and Implementation of Different Strategies written by OECD and published by OECD Publishing. This book was released on 2019-10-17 with total page 447 pages. Available in PDF, EPUB and Kindle. Book excerpt: This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.
Download or read book Hillcrest Medical Center Healthcare Documentation and Medical Transcription written by Patricia Ireland and published by Cengage Learning. This book was released on 2017-01-27 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: This innovative text uses a simulation approach to give readers interested in healthcare documentation and medical transcription careers a working knowledge of medical reports common in both acute and chronic care settings. Readers have access to transcription of 107 patient medical reports, including 56 new reports exclusive to the Eighth Edition. This edition also features 20 new speech recognition technology/medical editing (SRT) reports, as well as information on electronic health records (EHRs), quality assurance (QA), and scribes to keep readers up-to-date on the latest advances in the field. Organized by body system, the text includes full-color anatomy and physiology illustrations to make medical terminology easier to master. In addition, the authors have included a review of proper formatting, grammar, and style in accordance with the AHDI's BOOK OF STYLE, and a master glossary list compiles key terms in one section for convenient study and quick reference. Important Notice: Media content referenced within the product description or the product text may not be available in the ebook version.
Download or read book Legal Aspects of Documenting Patient Care for Rehabilitation Professionals written by Ronald W. Scott and published by Jones & Bartlett Learning. This book was released on 2006 with total page 214 pages. Available in PDF, EPUB and Kindle. Book excerpt: Because communication among health care professionals can mean the difference between patient life and death, clear and effective patient care documentation is as important as the delivery of care itself. The rehabilitation professional faces formidable documentation responsibilities. Patient care documentation created by the rehabilitation professional must be accurate, comprehensive, concise, objective, and timely. In an interdisciplinary health care environment, documentation must also be expeditiously communicated to other professionals on the health care team.
Download or read book The Clinical Documentation Improvement Specialist s Guide to ICD 10 written by Glenn Krauss and published by HC Pro, Inc.. This book was released on 2011-03 with total page 163 pages. Available in PDF, EPUB and Kindle. Book excerpt: Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in
