Medical Documentation Accuracy

Complying With Medical Record Documentation …

https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet

Download the Guidance Document. Final. Issued by: Centers for Medicare & Medicaid Services (CMS) Issue Date: April 01, 2017. DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including …

Ethical Standards for Clinical Documentation …

https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868

Facilitate accurate, complete, and consistent clinical documentation within the health record to demonstrate quality care, support coding and reporting of high-quality …

Documentation Matters Toolkit | CMS

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation

Clinical Documentation Integrity Education & Training

https://www.ahima.org/education-events/education-by-topic/

Leadership. Overview. Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, …

Importance of Documentation | Office of Inspector …

https://oig.hhs.gov/newsroom/oig-podcasts/importance-documentation/

Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate …

Electronic medical documentation: Attitudes and trends.

https://journals.lww.com/jaapa/Fulltext/2020/02000/Electronic_medical_documentation__Attitudes_and.9.aspx

Satisfaction with the medical documentation creation process as well as the end document itself have been shown to be imperative to electronic health record adoption and …

5 Best Practices for Medical Documentation - Clinical Advisor

https://www.clinicaladvisor.com/home/topics/practice-management-information-center/5-best-practices-medical-documentation/

1. Document Your Examination Failure to document a physical examination is the most common mistake I see. We may be missing this step when …

Implications of Clinical Documentation (In)Accuracy: A …

https://pubmed.ncbi.nlm.nih.gov/28332925/

Accurate and reliable medical records are necessary for assessing, improving, and reimbursing healthcare services. Clear and concise physician documentation is …

Clinical documentation | How to document medical …

https://onthewards.org/how-to-document-well/

Medical documentation is a document of service that has huge implications for hospital funding. Each issue that is documented is coded and then translated into a cost for the hospital system. Thorough …

Chapter 04: GUIDELINES FOR EFFECTIVE …

https://psu.pb.unizin.org/ptamedicaldocumentation/chapter/chapter-4_1/

Documentation elements for the initial examination/evaluation include the following: EXAMINATION: Includes data obtained from the history, systems review, and tests and …