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.
I promised in a previous “Standards of the month”column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.
