Dear residents , I am sharing this with you for improving documentation issue , Thanks for your understanding
PFA the Clinical Documentation Review Summary for the month of August.
The Word document contains the Progress Notes with names of responsible physicians and the excel data provides the summary and the names of physicians with corresponding deficiencies.
Below are the major issues that need your attention and appropriate action:
- Out of the 46 Coding Queries sent 31 were not responded, which is about 67% of total queries sent in August (Only one physician is responsible for 50% of the Queries not responded)
- Diagnoses documented without required specificity is still the main reason for a Coding Query
- Medication without supporting diagnosis and/or medical necessity is the top issue in Clinical Documentation Quality as before
As per Dr. Anwar of CIS the physicians can link diagnoses with medications in the Orders page and follow a simple step to let the details populate into the progress note, reducing the time & effort of physicians.
With this Medication Reconciliation can easily be resolved and we will have almost 50% improvement in documentation Quality.
Your feedback and continued support are highly essential for success of the program.
Thanks & Regards.