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.
It seems lately that every time you turn on the television there is a new medical drama starting. Unfortunately, the depiction of healthcare and the patient encounter is offered in a very skewed view depending on the story line and intended impact.
Clinical documentation improvement holds much promise for healthcare providers beyond the United States, including exciting opportunities for Al Ain Hospital, AWC’s newest organizational member, and other providers in the UAE related to International Refined Diagnosis-Related Groups.
How can we find a way to obtain the information without diverting more clinician energy and taking time away from the patient?
Every month, hospital-based health information management professionals must walk the thin line of ensuring adequate revenue is generated from submitted claims while maintaining quality during coding and pre-bill audits.
While neonatal abstinence syndrome is a serious condition, the lack of a standard clinical definition makes it difficult for providers to recognize the symptoms and accurately diagnose and treat newborns. If the syndrome is not recognized, and thus not documented, then the correct diagnosis code will not be assigned—which in turn impacts the state and national statistics regarding this syndrome.