The rules for making proper level-of-care decisions are lengthy and confusing, which makes the role of the physician advisor within the utilization review (UR) committee extremely critical.
It should come as no surprise that medical record documentation made the list for top standards noncompliance for the first half of 2010. Our old favorites just won’t go away.
Now that fall is in the air, hospitals may feel a chill as Medicare implements the Patient Protection and Affordable Care Act (PPACA) through the 2011 inpatient prospective payment system. Aspects include:
As physicians, we are quite aware of the severity of illness of the cancer patients we treat. However, we frequently are not cognizant of the elements of their diseases that need documentation or clarification in the medical record to accurately portray the complexity of those patients. I’d like to discuss some of the issues that surgeons, oncologists, family physicians, and pediatricians might face that need some attention in documentation.
Despite the numerous jokes on the subject, physician illegibility is no laughing matter, and Kaweah Delta Medical Center knows it. That’s why, after The Joint Commission found problems with the facility’s physician legibility, Kaweah Delta developed a plan to address the problem.
Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in actuality, everyone needs to work together for the success of the whole. "It's not an us vs. them concept, it's a we concept,"
