Comments on: Shadowing Physicians for Documentation Improvement http://journal.ahima.org/2009/09/01/shadowing-physicians-for-documentation-improvement/ The Journal of AHIMA is published monthly by the American Health Information Management Association Thu, 18 Mar 2010 21:33:28 -0500 http://wordpress.org/?v=2.9.1 hourly 1 By: Beth http://journal.ahima.org/2009/09/01/shadowing-physicians-for-documentation-improvement/comment-page-1/#comment-16897 Beth Tue, 16 Feb 2010 15:50:01 +0000 http://journal.ahima.org/?p=970#comment-16897 Coders should absolutely go into the patient rooms. I embarked on a similar project at my workplace and shockingly I found that some physicians were documenting physical exam areas they didn't examine. I was able to stop them right then and there from over-documenting. (Example: physician had PEERL defaulted in an EMR template, but didn't check for that on every patient). I'm certain this is a wide-spread problem, especially with EMRs. Coders should absolutely go into the patient rooms. I embarked on a similar project at my workplace and shockingly I found that some physicians were documenting physical exam areas they didn’t examine. I was able to stop them right then and there from over-documenting. (Example: physician had PEERL defaulted in an EMR template, but didn’t check for that on every patient). I’m certain this is a wide-spread problem, especially with EMRs.

]]> By: Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS http://journal.ahima.org/2009/09/01/shadowing-physicians-for-documentation-improvement/comment-page-1/#comment-11171 Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS Thu, 03 Sep 2009 11:48:02 +0000 http://journal.ahima.org/?p=970#comment-11171 Physician shadowing could be the ultimate win-win for the hospital AND the doc. Real time review could also provide help with the physician side of documentation and coding. It would also be an ongoing learning experience for the CDS as well. Great article! Physician shadowing could be the ultimate win-win for the hospital AND the doc. Real time review could also provide help with the physician side of documentation and coding. It would also be an ongoing learning experience for the CDS as well. Great article!

]]>