Description
Improve your CDI program and learn how to properly document clinical encounters to ensure compliance and accuracy.The electronic health record has negatively impacted and degraded the quality of the medical record from a communication of patient care perspective. Hospitals and health systems have taken the root of heavily investing in clinical documentation improvement initiatives with the outcome goal of improving revenue through casemix increases. A concomitant improvement in the quality and completeness of physician documentation has not been measurably achieved through current day approaches to CDI. This highly informative topic will be outlining and sharing how to capitalize upon the opportunity to harness the capabilities of current CDI programs to embrace process improvement in engaging physicians and the entire care team in a nonsiloed approach to achieving clinical documentation excellence. You will be able to define best practice standards and principles of documentation that best communicates patient care, applying these same standards and principles into daily chart reviews while addressing insufficiencies in documentation through a collaborative constituency approach working with physicians. Resources will be provided which are designed to be utilized as a how to roadmap for transformation of current CDI programs from reactive to proactive, driving achievement of clinical documentation excellence with optimal reimbursement while reducing medical necessity and clinical validation denials as well as financial and compliance exposure.
Date: 2020-03-10 Start Time: End Time:
Learning Objectives
The Role of the Medical Record- Going Beyond Reimbursement
• The Medical Record Serves a Myriad of Purposes Beyond a Repository for Physician Documentation That Supports Coding, Billing and Reimbursement. Learn How the Record Represents a Wide Array of Purposes Supporting and Facilitating Quality Focused Patient Centered Patient Care, All Fundamentally Dependent Upon Complete and Accurate Clinical Documentation That Best Describes, Shows and Tells the Patient Story
• Understand How the Electronic Health Record Has Degraded the Quality and Value of the Medical Record and What Steps Can Be Taken to Drive Clinical Documentation Excellence Through Deployment of Strategies That Engage Physicians
• Plan, Develop and Organize and Implement an Effective Strategy to Enhance the Quality and Completeness of the Medical Record, Utilizing a Team-Based Approach Incorporating All Stakeholders in a Multidisciplinary Approach on Behalf of the Patient and Quality Achieved Cost Effective Patient Outcomes
Addressing Insufficiencies in Physician Documentation- Expanding Traditional CDI Approaches
• Embrace Change in Current CDI Programs- Transform, Redesign, Reposition and Reengineer Present CDI Programs as the Backbone for Achieving Clinical Documentation Excellence
• Outline and Discuss Key Elements of an Effective CDI Program Necessary for Successful Transformation That Creates a Vision That Inspires Physicians, the Care Team and All Relevant Health care Stakeholders to Work Together to Consistently Achieve Clinical Documentation Excellence
• Share Two CDI Program Development Case Studies, Highlighting Operational Processes and Redesign Required as Well as Key Performance Indicators Established and Implemented to Achieve Solid Performance in Clinical Documentation Excellence That Was Sustainable Over Time
Defining Best Practice Standards and Principles of Physician Documentation for Effective Patient Care Communication
• Define Best Practice Standards and Principles of Physician Documentation That Communicates Patient Care Effectively Using Real Case Studies Outlining Insufficient Versus Sufficient Documentation
• How CDI Programs Can Incorporate Best Practice Standards and Principles of Clinical Documentation Into Present Day CDI Programs With a Focus Upon Physician Learnings and Teachings Extending Beyond the Traditional Query Process
• The Physician Advisor as the Leader and Change Agent in Transforming Current CDI Efforts From Reimbursement to Quality and Completeness of Documentation- It Is All About the Patient
Douglas Cutler-Northern Arizona Hospitalists
