Clinical care is recorded in the medical record. This is the only evidence to demonstrate and record the work of the care team.
WHYClinical documentation forms the backbone of all quality measures, clinical and fiscal. All billing starts from clinical documentation of patient care. Documentation must always be timely, efficient, accurate, reliable and thorough.
WHOEvery agency, every staff person.
WHENEvery day, every visit.
TO DOEnsure all front line caregivers understand how to document, have access to the appropriate tools (forms, computers, internet connection, etc.), establish auditing procedures to support staff and for success.
RISKDocumentation falures leave patient care at risk for gaps and inconsistencies. It leaves the organization at risk for fiscal auditing and compliance audits.
OASIS-C1, Coding , and the New Recalibrations: What This Can Mean for Your Agency (Webinar Archive)
ICD-10 Coding, Part 1: Overview and Planning (Webinar Archive)
ICD-10 Coding, Part 2: Drilling Down to the Details (Webinar Archive)
ICD-10 Coding, Part 3: Checklists for Success (Webinar Archive)
Outcome and Assessment Information Set (CMS)
The Complete ICD-10 Guide (Axxess)
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