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When biometric scanning was introduced at Carolinas HealthCare System in Charlotte, NC, registrars handed out marketing and informational material to all patients.
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If you don't have a robust clinical documentation improvement program implemented by highly trained staff, your hospital might find itself in trouble in more ways than one.
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A few years ago, it was a common practice for case managers to be responsible for clinical documentation improvement along with their other duties, but that should no longer be the case, according to Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts, a case management consulting firm.
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As a result of a pre-billing review of charts of patients who die in the hospital, the mortality index at Stony Brook University Medical Center has remained steady at under 1 except for one month when it was 1.04, according to Catherine Morris, RN, MS, CCM, CMAC, executive director of care management and clinical documentation improvement administrator at the 591-bed medical center in Stony Brook, NY.
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Case managers are likely to have additional duties added to their workload under a proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) that would require providers to formally notify Medicare beneficiaries of their right to communicate concerns about the quality of the care they received to the state Quality Improvement Organization (QIO).
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As reform helps more Americans gain access to health coverage, experts predict that the nation's EDs will be bulging at the seams.
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The report card that begins below is an example of a method for aggregating and reporting all the measures that we have reviewed in the last two issues.
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When Stony Brook University Medical Center presented an educational program to its urology staff about the importance of using the correct terms in documentation, the physicians pointed out that in medical school, they learned to write "urosepsis" on the chart for patients who had developed sepsis from a severe urinary tract infection, according to Catherine Morris, RN, MS, CCM, CMAC, executive director of care management and clinical documentation improvement administrator at the 591-bed regional hospital in Stony Brook, NY.
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After working with a consultant to determine how to improve clinical documentation, the care coordination department at Wake Forest Baptist Medical Center in Winston-Salem, NC, revamped its clinical documentation program, adding more staff and shifting the team from unit-based to service-based.
