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 Documentation for Medical Records written by Barbara Odom-Wesley and published by . This book was released on 2008-08 with total page 538 pages. Available in PDF, EPUB and Kindle. Book excerpt:
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 385 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 The Medical Documentation of Torture written by Michael Peel and published by Cambridge University Press. This book was released on 2002-01-03 with total page 248 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book will be of practical use to doctors writing medical reports on alleged victims of torture or lawyers working in this field. It will also be of value to psychologists, human rights activists and academic researchers at all levels who are engaged in the documentation of torture.
Download or read book Clinical Handbook of Psychiatry the Law written by Paul S. Appelbaum and published by Lippincott Williams & Wilkins. This book was released on 2007 with total page 348 pages. Available in PDF, EPUB and Kindle. Book excerpt: Thoroughly updated for its Fourth Edition, this award-winning handbook gives mental health professionals authoritative guidance on how the law affects their clinical practice. Each chapter presents case examples of legal issues that arise in practice, clearly explains the governing legal rules, their rationale, and their clinical impact, and offers concrete action guides to navigating clinico-legal dilemmas. This edition addresses crucial recent developments including new federal rules protecting patients' privacy, regulations minimizing use of seclusion and restraint, liability risks associated with newer psychiatric medications, malpractice risks in forensic psychiatry, and new structured assessment tools for violence risk, suicidality, and decisional capacity.
Download or read book Medical Terminology Documentation and Coding written by Anne P. Stich and published by Routledge. This book was released on 2018-01-12 with total page 822 pages. Available in PDF, EPUB and Kindle. Book excerpt: Giving students the strongest possible baseline in medical terminology, along with the how and why it is used in documentation and basic coding, this is a vital text for all students taking courses in the area. It allows readers to use their knowledge immediately in any medical setting (including being a patient), in their workplaces, and in the journey to future careers. Using a body systems approach to medical terminology, this textbook supports students to: Recognize words by constructing medical terms based on root words, prefixes, linking forms, and suffixes. Define, spell, pronounce, and use medical terms, acronyms, and abbreviations in the context of patient care with appropriate documentation and coding examples. Identify anatomical directions, fundamental anatomical terminology, basic physiologic functions, and common pathology of all major organ systems with related medical investigation tools, procedures, and pharmaceuticals. Relate the use of medical language and medical record-keeping to the SOAP format, common medical reports, and coding tools, along with their impact on patient care. Accompanied by plentiful color illustrations and activities, as well as a companion website with resources for both instructors and students, this is a fresh and readable textbook.
Download or read book The Computer Based Patient Record written by Committee on Improving the Patient Record and published by National Academies Press. This book was released on 1997-10-28 with total page 257 pages. Available in PDF, EPUB and Kindle. Book excerpt: Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.
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 Medical Record Auditor written by Deborah J. Grider and published by American Medical Association Press. This book was released on 2011 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: "This book helps readers understand the principles of medical record documentation and chart auditing. It introduces readers to principles of medical record documentation and how to conduct a medical record chart review in the physcian's or outpatient office"--Provided by publisher.
Download or read book Electronic Health Record written by Pradeep K. Sinha and published by John Wiley & Sons. This book was released on 2012-11-27 with total page 244 pages. Available in PDF, EPUB and Kindle. Book excerpt: Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics," which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications. Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved. This book on Electronic Health Record: Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others Provides assessment of existing standards Includes a glossary of frequently used terms in the area of EHR Contains numerous diagrams and illustrations to facilitate comprehension Discusses security and reliability of data
Download or read book Writing Patient Client Notes written by Ginge Kettenbach and published by F.A. Davis. This book was released on 2016-05-11 with total page 295 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.
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 How to Practice Academic Medicine and Publish from Developing Countries written by Samiran Nundy and published by Springer Nature. This book was released on 2021-10-23 with total page 475 pages. Available in PDF, EPUB and Kindle. Book excerpt: This is an open access book. The book provides an overview of the state of research in developing countries – Africa, Latin America, and Asia (especially India) and why research and publications are important in these regions. It addresses budding but struggling academics in low and middle-income countries. It is written mainly by senior colleagues who have experienced and recognized the challenges with design, documentation, and publication of health research in the developing world. The book includes short chapters providing insight into planning research at the undergraduate or postgraduate level, issues related to research ethics, and conduct of clinical trials. It also serves as a guide towards establishing a research question and research methodology. It covers important concepts such as writing a paper, the submission process, dealing with rejection and revisions, and covers additional topics such as planning lectures and presentations. The book will be useful for graduates, postgraduates, teachers as well as physicians and practitioners all over the developing world who are interested in academic medicine and wish to do medical research.
Download or read book Documentation for Physical Therapist Assistants written by Wendy D Bircher and published by F.A. Davis. This book was released on 2017-10-01 with total page 305 pages. Available in PDF, EPUB and Kindle. Book excerpt: Build your documentation skills—and your confidence. Step by step, this text/workbook introduces you to the importance of documentation; shows you how to develop and write a proper and defensible note; and prepares you to meet the technological challenges you’ll encounter in practice. You’ll learn how to provide the proper documentation to assure all forms of reimbursement (including third party) for your services. You’ll also explore issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society.
Download or read book Effective Documentation for Physical Therapy Professionals written by Eric Shamus and published by McGraw-Hill Medical. This book was released on 2004 with total page 276 pages. Available in PDF, EPUB and Kindle. Book excerpt: This is a comprehensive textbook for the documentation course required in all Physical Therapy programs. The textbook incorporates current APTA terminology and covers every aspect of documentation including reimbursement and billing, coding, legal issues, PT and PTA communication, as well as utilization review and quality assurance. (Midwest).
Download or read book ICD 10 CM Official Guidelines for Coding and Reporting FY 2021 October 1 2020 September 30 2021 written by Department Of Health And Human Services and published by Lulu.com. This book was released on 2020-09-06 with total page 128 pages. Available in PDF, EPUB and Kindle. Book excerpt: These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Download or read book StatNote written by Gerardo Guerra Bonilla MD and published by . This book was released on 2019-07-31 with total page 342 pages. Available in PDF, EPUB and Kindle. Book excerpt: As a primary care physician, you know that completing clinic notes while you're treating many patients is time-consuming and challenging. That's why StatNote, a library of more than 1,000 medical templates, was created for you. It reduces busy work and enables you to focus on the most important part of the office visit: your patient.StatNote's dot phrases help you: - Efficiently document office visits and common procedures. - Write patient messages in English and Spanish to communicate lab and imaging results. - Easily retrieve common evaluation and management (E&M) and current procedural terminology (CPT) codes used for billing.This book familiarizes you with all the available boilerplate templates. An electronic version can be purchased at statnote.com and used with a text expander in any Electronic Health Record (EHR) system.
