Many organizations develop physician documentation tip sheets based on the clinical topics appropriate to their specific facility. Some handouts are a simple piece of paper developed by a clinical documentation improvement team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program. Several samples donated by members of the Association of Clinical Documentation Improvement Specialists (ACDIS) are available on its website at www.hcpro.com/acdis. (See p. 11 for a sample.)
“In my opinion, [ICD-10 implementation] is the biggest change in healthcare since the implementation of DRGs back in the early ’80s,” said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. McCall and Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, spoke during HCPro’s November 18 audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.”
The last thing you need is more to do, but when it comes to preparing your HIM department for EHR go-live, an ounce of prevention is worth a pound of cure.
Methodist South Hospital in Memphis, TN, began using the Situation, Background, Assessment, and Recommendation (SBAR) tool to meet two basic needs: standardizing communication across the facility and managing complex cases.
