On October 1, 2013, the ICD-10-CM and ICD-10-PCSclassification systems will take effect, and should result in better data capture nationwide. The change means healthcare organizations urgently need to educate providers on the importance of improved patient care documentation.
Editor's note: There are a number of ways to get information into the hands of your facility's physicians. The following list offers several suggestions on how to train and engage your medical staff. This article was adapted from the October issue of CDI Journal, a quarterly publication for members of the Association of Clinical Documentation Improvement Specialists (ACDIS). Additional information is available at www.acdis.org.
Legible.Complete.Dated, timed, signed, and authenticated.That's what section 482.24 of the Medicare Conditions of Participation requires of your medical records.
