Guide to Clinical Documentation

Author: Debra Sullivan
Publisher: F.A. Davis
ISBN: 9780803629974
Release Date: 2011-12-22
Genre: Medical

Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

The Physician Advisor s Guide to Clinical Documentation Improvement

Author: Trey La Charite
Publisher: Hcpro, a Division of Blr
ISBN: 1615693475
Release Date: 2014-04-30
Genre: Medical

The Physician Advisor's Guide to Clinical Documentation Improvement Physician advisors are not just needed for case management anymore. ICD-10-CM/PCS and the changing landscape of healthcare reimbursement make their input invaluable in the realm of CDI and coding, too. This book will help your physician advisors quickly understand the vital role they play and how they can not only help improve healthcare reimbursement, but also reduce claims denials and improve the quality of care overall. This book will: * Provide job descriptions and sample roles and responsibilities for CDI physician advisors * Outline the importance of CDI efforts in specific relation to the needs and expectations of physicians * Highlight documentation improvement focus areas by Major Diagnostic Category * Review government initiatives and claims denial patterns, providing physician advisors concrete tools to sway physician documentation

Documentation for Rehabilitation

Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 9780323312349
Release Date: 2015-11-18
Genre: Medical

Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you’ve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model — the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies — especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. EXPANDED number of case examples covers an even broader range of clinical practice areas.

Clinical Skills Documentation Guide for Athletic Training

Author: Herb Amato
Publisher: SLACK Incorporated
ISBN: 1556427581
Release Date: 2006-01-01
Genre: Medical

Athletic training students are required to learn, practice, test, and master clinical skill sets throughout their educational career. A textbook that can be used from the start of their education up until graduation becomes essential to this learning process. Answering the call for educators and students is Clinical Skills Documentation Guide for Athletic Training, Second Edition. The esteemed Practical Exam Preparation Guide of Clinical Skills for Athletic Training has been updated, revised, and renamed to accurately reflect the material presented throughout the text that is necessary for athletic training students to master clinical skill sets as tested on throughout their educational career. Herb Amato, Christy D. Hawkins, and Steven L. Cole have revised and updated Clinical Skills Documentation Guide for Athletic Training, Second Edition to reflect the standards and specific outcomes of the Clinical Proficiencies as established by the National Athletic Trainers’ Association. Incorporating the "Learning Over Time Concept”, this second edition presents a three-weighted practical exam format within the Evaluation Box for each clinical skill set. Additionally, each clinical skill sets follows an easy-to-use checklist design, allowing athletic training students to learn, practice, test, and master clinical skills. New features inside the Second Edition: * Over 110 new clinical skills sets--393 in total throughout the text. * Chapters have been re-organized in a more user-friendly fashion. * Updated references throughout the text. New sections inside the Second Edition: * Joint mobilization * General medical * Therapeutic exercise/re-conditioning * Therapeutic modalities * Therapeutic measurements Athletic training educators will find Clinical Skills Documentation Guide for Athletic Training to be a user-friendly text that will easily supplement their curriculum for a way to document when clinical skills have been taught, practiced, evaluated, and mastered by each student. With new chapters reflecting the progressing field of athletic training, a re-organization of the information presented, and the addition of 110 new clinical skill sets, Clinical Skills Documentation Guide for Athletic Training, Second Edition is the critical first step necessary in developing clinical skill set mastery for athletic training students.

The Clinical Documentation Improvement Specialist s Guide to ICD 10

Author: Glenn Krauss
Publisher: HC Pro, Inc.
ISBN: 9781601468178
Release Date: 2011-03-01
Genre: Medical

Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in

Clinical Documentation Improvement

Author: Rn Phn Nkwuaku, Msn Cphq
Publisher: Createspace Independent Publishing Platform
ISBN: 1519538189
Release Date: 2015-12-17

Clinical Documentation Improvement (CDI) Made Easy is a great resource and reference that every Clinical Documentation Improvement Specialist/Professional (CDIS/CDIP), coder, physician champion/advisor, and others involved in the CDI must have. The book is a compendium of sound clinical knowledge and experience, clinical documentation expertise, and quality, which will help the CDIS/CDIP and others maximize their potentials in performing their core duties. Whether you are a new CDIS trying to learn CDI or an experienced CDIS hoping to stay current with CDI world, or involved in the CDI, this book will be very valuable to you. Remember, accurate and quality documentation is a reflection of great patient care. "If it wasn't documented, and documented accurately, it never happened." This book clearly explained various query opportunities by Major Disease Classifications (MDCs) with some sample queries. It defines and analyses different disease processes, creates CDIS awareness and what to look for under various MDCs, ICD-10-CM/PCS, explained current CMS Pay for Performance (P4P), and the CDI responsibility under P4P, explained some pertinent coding guidelines, 2016 Official Coding Guidelines for Coding and Reporting, AHIMA/ACDIS practice brief for queries and compliance, and much more. I have no doubt in my mind that this book is a concise but a comprehensive tool and reference that anyone involved in CDI should always have at his/her side. The Author Anthony O Nkwuaku, RN, PHN, MSN, CPHQ, CCDS is very knowledgeable and experienced as a clinician, clinical instructor, and Clinical Documentation Improvement Specialist.

The Clinical Documentation Improvement Specialist s Guide to ICD 10

Author: Jennifer Avery
Publisher: Hcpro, a Division of Blr
ISBN: 1615692002
Release Date: 2013-05-07
Genre: Medical

Now in its second edition, The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only guide to address ICD-10 from the CDI point of view. Written by CDI experts and ICD-10 Boot Camp instructors, it explains the ICD-10 documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code a variety of conditions. The CDI Specialist's Guide to ICD-10, 2nd edition, not only outlines the changes coming in October 2014, it provides detailed information on how to assess staffing needs, training requirements, and implementation strategies. The authors-an ICD-10 certified coder and CDI specialist-collaborated to create a comprehensive selection of ICD-10 sample queries facilities can download and use to jumpstart ICD-10 documentation improvement efforts. Develop the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. The Clinical Documentation Improvement Specialist's Guide to ICD- 10, 2nd ed. is part of the library of products and services from the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS members are CDI professionals who share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Member benefits include a quarterly journal, members-only Web site, quarterly networking conference calls, discounts on conferences, and more. WHAT'S NEW? Completely revised to accommodate changes in ICD-10 implementation dates Dozens of targeted ICD-10 physician queries Updated ICD-10 benchmarking reports BENEFITS Sample ICD-10 queries Specificity requirements and clinical indicators by disease type and body system Staff training and assessment tools

Complete Guide to Documentation

Author: Lippincott Williams & Wilkins
Publisher: Lippincott Williams & Wilkins
ISBN: 1582555567
Release Date: 2008
Genre: Medical

Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.

The Clinical Documentation Improvement Specialist s Complete Training Guide

Author: Laurie L. Prescott (R. N.)
ISBN: 1556452837
Release Date: 2014-10-01

Your new CDI specialist starts in a few weeks. They have the right background to do the job, but need orientation, training, and help understanding the core skills every new CDI needs. Don't spend time creating training materials from scratch. ACDIS' acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist's Complete Training Guide to serve as a bridge between your new CDI specialists' first day on the job and their first effective steps reviewing records. The Clinical Documentation Improvement Specialist's Complete Training Guide is the perfect resource for CDI program managers to help new CDI professionals understand their roles and responsibilities. It will get your staff trained faster and working quicker. This training guide provides: An introduction for managers, with suggestions for training staff and guidance for manual use Sample training timelines Test-your-knowledge questions to reinforce key concepts Case study examples to illustrate essential CDI elements Documentation challenges associated with common diagnoses such as sepsis, pneumonia, and COPD Sample policies and procedures

Clinical Documentation Improvement Specialist s Handbook

Author: Colleen Garry
Publisher: HC Pro, Inc.
ISBN: 9781601467751
Release Date: 2011-01-01
Genre: Medical

Improving documentation is no easy task CDI professionals have never had one easy-to-read, inclusive reference to help them implement a CDI program, understand the fundamentals of ICD-9-CM coding, query physicians, and encourage interdepartmental communication. In theory, physicians should document their entire thought process, including ruling conditions in and out. But it's not that simple, and in light of MS-DRGs, it requires significant physician education and retraining. You need a blueprint for success.. Your blueprint has arrived! At last, here is a guide for CDI specialists. The Clinical Documentation Improvement Specialist's Handbook is your essential partner for creating a CDI program, staffing your program, querying physicians, and understanding how documentation affects code selection and data quality As a CDI specialist you need answers now In light of Medicare Severity DRGs (MS-DRG), detailed documentation and accurate capture of complications and comorbidities (CCs) has made the CDI specialist's role more important and more demanding than ever. This handbook will enhance your ability to gather the right information the first time--and every time Author Colleen Garry, RN, BS, has compiled case studies that document best practices and reference several different CDI models so that you can select the one that's right for your hospital's CDI success. In addition, you'll be privy to an executive summary of HCPro's exclusive CDI survey that solicited more than 800 responses. Learn how other hospitals are handling CDI and choosing the model that works best for them. * work with physicians to obtain detailed, appropriate documentation * maintain compliance when performing physician queries * convey return on investment for a CDI program Customizable CD-ROM included Your copy of The Clinical Documentation Improvement Specialist's Handbook includes a CD-ROM loaded with all of the working tools you'll find in the book. Among them

A Physician s Guide to Clinical Forensic Medicine

Author: Margaret M. Stark
Publisher: Springer Science & Business Media
ISBN: 9781592590223
Release Date: 2000-01-31
Genre: Medical

Margaret Stark and a team of authoritative experts offer a timely survey of the fundamental principles and latest developments in clinical forensic medicine. Topics range from sexual assault examination to injury interpretation, from nonaccidental injury in children, to crowd control agents. Also included are extensive discussions of the care of detainees, the management of substance abuse detainees in custody, the causes and prevention of deaths in custody, and the fundamentals of traffic medicine. In the absence of international standards of training, the authors also address the basic issues of consent, confidentiality, note-keeping, court reporting, and attendance in court. Comprehensive and authoritative, A Physicians Guide to Clinical Forensic Medicine offers forensic specialists and allied professionals a reliable, up-to-date guide to proven practices and procedures for a every variety of police inquiry requiring clinical forensic investigation.