Technology does not always function as planned, even now in the era of electronic health records. Proper documentation is essential for data integrity and the integrity of the medical record. This documentation enables staff to identify when a system issue has occurred and to determine the impact on the medical record.
“Remedial measures,” also known as “sanctions,” can be imposed under Federal Rule of Civil Procedure 37(e) when electronically stored information is lost. The word “lost” has a specialized meaning in this context
Clinical documentation improvement is a provider’s best defense against payment denials, audits, and preserving revenue integrity—which is why the people sitting in the C-suite should know what it is and prioritize it.
Systemic problems from the opioid crisis to mass shootings are linked to the overarching problem of underfunded and underworked mental health services, a problem that Silicon Valley is seeking to address with mobile health apps. At the same time, legislators are introducing legislation aimed at improving privacy protections of unregulated health apps.
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