Clinical Documentation Improvement Intro and Chapter 1 revised.

Clinical Documentation Improvement Intro and Chapter 1 revisedWhat is clinical documentation? - answerany manual or electronic notation (or recording) made by a physician or other healthcare clinician related to a patient's medical condition or treatment. Pg. xiii What is the seven criteria that meets quality clinical documentation? - answerLegible, Reliable, Precise, Complete, Consistent, Clear, and Timely Pg. xiii Healthcare organizations are medical trustees for what? - answerTheir patients' protected health information Pg. xiii What does the acronym HIPAA stand for? - answerHealth Information Portability and Accountability Act pg. xiii What is the next challenge for the healthcare industry? - answerensuring consistency and content and meaning of clinical information as it evolves from manual to an electronic practice Pg. xiii What does the acronym PACS? - answerPicture Archive Communication System What is the subsequent challenge for the healthcare industry? - answerdigitally compiling all health information about one patient into a common location. Pg xiii What is the goal of every clinical documentation improvement (CDI) program? - answerHigh-quality clinical documentation Pg. xiv What is the primary purpose for maintaining a health record? - answer"accurately and adequately document a patient's life and health history, including the past and present illness(es) and treatment(s), with emphasis on the events affecting the patients during the current episode of care." (Huffman 1994, 30). P what is the primary reference tool for all physicians and clinicians treating the patient? - answerThe health record Pg. xiv What is the key factor in determining the quality of care provided to the patient? Hint: its the foundation of the patient's record. - answerClinical documentation pg. xiv Who has raised awareness about patients' rights concerning their health information and has increased the popularity of electronic health records? - answerHealth Information Portability and Accountability Act (HIPPA) pg xv What is a primary tool for clinicians to communicate with each other about a patient? - answerA health record pg xv The typical hospital record includes entries made by whom? - answerattending physician, specialists, house staff, nurses, radiologists, pathologists, and therapists pg. xv What can create a domino effect that negatively impacts the quality of care provided to the patient? - answerThe inaccurate or unreliable clinical documentation of one provider pg. xv Who are not thoroughly trained in the principles of high-quality clinical documentation based on a survey? - answerMedical School Students, residents and most clinicians pg. xv What may be the most valuable asset of a healthcare organization? - answerhealth records and clinical documentation pg. xv What is evidence that the care billed for was in fact provided to the patient? - answerEach record pg xv Health records create a data set that healthcare organizations rely upon for what? - answerstrategic and financial planning, budgeting, and internal research pg xv A hospital's senior management team can trend what? - answertreatment and resource needs, staffing requirements, and disease patterns by reviewing the diagnostic data gleaned from the clinical documentation in patients' records. pg xv The trustworthiness if management decisions in the healthcare industry is what? - answerdirectly proportional to the quality if the clinical documentation in patient records pg xv What do insurers pay for? - answercare that was provided to their subscribers subject to the policy limitations pg. xv Most insurers perform what because no plan will pay for care that was not provided? - answerperform regular audits of documentation in patient health records What are the users oh health information? - answerPatients, Physicians and other clinicians, Healthcare Provider Organizations, Insurers, Government and regulatory Agencies, and Research organizations and the Pharmaceutical Industry pg. xiv What are some organizations that publish healthcare quality ratings? - answerThe Joint Commission, HealthGrades, the LeapFrog Group and other organizations pg. xvi Who else plays a regulatory role in measuring and attempting to ensure a certain level of quality in healthcare? - answerthe government At the federal level who else plays an important role in comparative measurement among healthcare organizations? - answerThe Medicare quality indicators pg xvi Accreditation organizations also produce what? - answermeasures that are use by healthcare consumers and insurers to select healthcare providers pg xvi To some degree, all quality measurements rely upon what? - answerclinical documentation in the patient's records and the resulting coded data pg xvi A large percent of clinical documentation research is sponsored by whom? - answerresearch organizations and the pharmaceutical industry. pg xvi .