The Beginning, Middle and End
EVERY patient story has a beginning, middle and ending. The Medical Record needs to tell the patient's story consistently from first encounter through admission and discharge.
The Copy & Paste Solution
Copy & Paste is only effective if you UPDATE the text. "No acute changes overnight" is simply not descriptive enough, and the Physician Assesment should be constantly (daily) updated.
Case Studies given in Each Lesson
Real world case studies are (unfortunately) readily available for teaching in each lesson, illustrating what is not so good versus what would have been much better in the medical record.
Keys for High-Value Diagnoses
The most common high-value diagnoses are readily familiar, and are illustrated with simple explanations of exactly what auditors are looking to see documented in the medical record.
Our Clients were asking: What Do BOTH Physicians and Auditors Need to See in the Medical Record?
And what do your Physicians need to learn about what to make sure they put into the medical record without fail?
Here's our answers in four pointed educational videos
about exactly those critical points.
A Beginning, Middle, End in Every Story
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Portrays patient’s visit from first clinical encounter until discharge
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MUST have consistent documentation across all attending providers
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Medical Necessity & Level of Care must validate all Acute Dx
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Must include what has occurred Daily with Each Dx
Avoiding Clinical/Temporal Disconnects
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First clinical encounter = high severity Dx, but later no acute distress
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Assessment of high severity Dx thereafter…does NOT “connect”
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ED = acute diagnosis, but later, Attending reports no longer acute
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Assessment later reports acute Dx, does not “connect” temporally
Copy & Paste vs. Review & Edit
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“Cloned” notes WILL nullify Medical Necessity
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If they see No evident change in the assessment day-to-day
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If they see No evident change in the subjective note day-to-day
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Then Payers then doubt patient was even treated, much less needed it
High Severity Dx: What Payers Look For
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Keys in Review of Sepsis
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Keys in Review of Severe Malnutrition
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Keys in Review of Acute Encephalopathy
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Keys in Review of any type of Acute Respiratory Failure
Four Videos or Podcasts. Take Your Pick.
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