clinical documentation improvement (CDI) roles are being increasingly created in Australian hospitals. It is important to understand what good clinicaldocumentation is and who is responsible for it as well as what th...
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clinical documentation improvement (CDI) roles are being increasingly created in Australian hospitals. It is important to understand what good clinicaldocumentation is and who is responsible for it as well as what these roles potentially offer our health system. This article explores the role of a CDI specialist, the benefits and pitfalls of clinical documentation improvement programs, and mounts an argument that health information managers and clinical coders are uniquely placed to fill these roles in Australian hospitals.
Complete and accurate clinicaldocumentation in the medical record has a direct impact on the assignment of codes, more accurate levels of reimbursement, and is critical to the higher quality of patient care. This pap...
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ISBN:
(纸本)9781538654880
Complete and accurate clinicaldocumentation in the medical record has a direct impact on the assignment of codes, more accurate levels of reimbursement, and is critical to the higher quality of patient care. This paper describes the development of a system which can automatically flag the cases if there is an opportunity of improvement in patient clinical documents. Automated clinical documentation improvement (CDI) leverages the natural language processing (NLP) and contextual understanding of health record structure with additional business rules logic, helping CDI specialists identify critical documentation information that may be missing from the medical record. This results in more specific coding opportunity and better understanding of the clinical complexity for accurate reimbursement. This system helped increase CDI specialists' productivity by efficiently filtering cases which need more attention from them.
Background Severity of illness (SOI) is an All Patients Refined Diagnosis Related Groups (APR DRG) modifier based on comorbidity capture. Tracking SOI helps hospitals improve performance and resource distribution. Fur...
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Background Severity of illness (SOI) is an All Patients Refined Diagnosis Related Groups (APR DRG) modifier based on comorbidity capture. Tracking SOI helps hospitals improve performance and resource distribution. Furthermore, benchmarking SOI plays a key role in Quality improvement (QI) efforts such as clinical documentation improvement (CDI) programs. The current SOI system highly relies on the 3 M APR DRG grouper that is updated annually, making it difficult to track severity longitudinally and benchmark against hospitals with different patient populations. Here, we describe an alternative SOI scoring system that is grouper-independent and that can be tracked longitudinally. Methods Admission data for 2019-2020 U.S. News and World Report Honor Roll facilities were downloaded from the Vizient clinical Database and split into training and testing datasets. Elixhauser comorbidities, body systems developed from the Healthcare Cost and Utilization Project (HCUP), and ICD-10-CM complication and comorbidity (CC/MCC) indicators were selected as the predictors for orthogonal polynomial regression models to predict patients' admission and discharge SOI. Receiver operating characteristic (ROC) and Precision-Recall (PR) analysis, and prediction accuracy were used to evaluate model performance. Results In the training dataset, the full model including both Elixhauser comorbidities and body system CC/MCC indicators had the highest ROC AUC, PR AUC and predication accuracy for both admission (ROC AUC: 92.9%;PR AUC: 91.0%;prediction accuracy: 85.4%) and discharge SOI (ROC AUC: 93.6%;PR AUC: 92.8%;prediction accuracy: 86.2%). The model including only body system CC/MCC indicators had similar performance for admission (ROC AUC: 92.4%;PR AUC: 90.4%;prediction accuracy: 84.8%) and discharge SOI (ROC AUC: 93.1%;PR AUC: 92.2%;prediction accuracy: 85.6%) as the full model. The model including only Elixhauser comorbidities exhibited the lowest performance. Similarly, in the validation da
Complete and accurate clinicaldocumentation in the medical record has a direct impact on the assignment of codes, more accurate levels of reimbursement, and is critical to the higher quality of patient care. This pap...
详细信息
ISBN:
(纸本)9781538654897
Complete and accurate clinicaldocumentation in the medical record has a direct impact on the assignment of codes, more accurate levels of reimbursement, and is critical to the higher quality of patient care. This paper describes the development of a system which can automatically flag the cases if there is an opportunity of improvement in patient clinical documents. Automated clinical documentation improvement (CDI) leverages the natural language processing (NLP) and contextual understanding of health record structure with additional business rules logic, helping CDI specialists identify critical documentation information that may be missing from the medical record. This results in more specific coding opportunity and better understanding of the clinical complexity for accurate reimbursement. This system helped increase CDI specialists' productivity by efficiently filtering cases which need more attention from them.
Although nursing documentation is very important for patient safety, it forces nurses to spend increasing amounts of their working time completing it. In this study, I evaluated the time lag between patient events to ...
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ISBN:
(纸本)9789897581809
Although nursing documentation is very important for patient safety, it forces nurses to spend increasing amounts of their working time completing it. In this study, I evaluated the time lag between patient events to completion of nursing documentation at two Post-Acute Care settings (called as "Care-Mixed Hospital" in Japan, similar to nursing home). The mean time lag at Hospital A, which did not implement an automatic documentation system (ADS) was 197.3 min [progress note regarding vital signs (VS), 208.2 min and the others, 196.1 min. The mean time lag at Hospital B, which had implemented ADS, was 3.2 min (only progress note regarding VS). ADS is effective in improving instantaneity on nursing documentation at post-acute care settings.
Purpose - Complete health documentation during childbirth can reduce complications and improve maternal and foetal outcomes. One such document is the partograph which allows health workers to record and follow the lab...
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Purpose - Complete health documentation during childbirth can reduce complications and improve maternal and foetal outcomes. One such document is the partograph which allows health workers to record and follow the labour progress. However, the completion rates of partograph remain low in some hospitals. This study describes the implementation of a quality improvement project to increase the completion rate of partograph in a district hospital in Rwanda. Design/methodology/approach - The project team tackled the root cause of partograph incompletion by implementing a labour monitoring guideline, assigning patients and duties to midwives and by providing support and supervision. Findings - The intervention successfully increased overall partograph completion rates from 11 to 61 per cent, p < 0.001. This study also showed that completeness of the partograph was statistically associated with a decrease in foetal deaths and higher Apgar score with p < 0.001 for both. Practical implications - This study describes the establishment of a quality improvement project following the strategic problem solving approach to increase the completion rate of partograph documentation. The intervention was simple, data-driven and cost-neutral. The team achieved its objectives by integrating staff input, obtaining commitment from the multidisciplinary team and applying leadership skills. Originality/value - The results are useful for hospitals in limited resources settings wishing to improve overall partograph completion and improve foetal and maternal outcomes during labour, in an efficient and cost-neutral way.
The purpose of this article is to introduce the fundamental concepts of utilization review, a process used by hospitals to ensure that patients are receiving optimal care in the appropriate setting. Criteria for the t...
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The purpose of this article is to introduce the fundamental concepts of utilization review, a process used by hospitals to ensure that patients are receiving optimal care in the appropriate setting. Criteria for the types of hospital admission status are discussed in addition to an outline of the screening functions performed by members of the hospital utilization review team. Basic health care payment methodology is explored, including the recent impact of medical necessity denials through government audit programs.
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