It is essential to base your clinical documentation training on the objective, well-defined theory of high quality clinical documentation (HQCD). The theory holds that high quality documentation meets seven criteria, all derived from official sources including the Medicare Conditions of Participation, the Joint Commission, the Office of the Inspector General’s Hospital Compliance Guidance and the American Health Information Management Association’s practice briefs. These criteria (legibility, timeliness, clarity, completeness, consistency, reliability and precision) are described in detail during this session. Documentation examples of each criteria are shared with participants.
You will learn the value of using the criteria for HCQD as a structure that physicians can process in a more scientific manner than the approaches used in traditional clinical documentation training. You will learn how to walk physicians through the criteria and application so they can apply the criteria to their own clinical documentation practices.
Audio Sample From this Session:
Session tools
Case studies/examples for each criteria for HQCD
Power Point slides for training physicians on the seven criteria for HQCD
Sample medical record documentation that does not meet one or more of the seven criteria
Template tool for HQCD for physicians’ reference
Objectives
Define and provide examples of each of the seven criteria for high quality clinical documentation
Describe the specific methodology for teaching the criteria using CAMP™ Method components of coaching, asking, mastering and peer learning
Review the practical application of documentation practices using HQCD to be used during the actual training sessions
Demonstrate how the use of criteria for HQCD as a basis for training lays the groundwork for both a more compliant CDI program and program compliance
Intended audience:
Clinical documentation managers
Nurse managers
Clinicians/managers who document in the patient record
Coders
Case managers
Case Mix managers
Compliance reviewers and managers
Health information managers
Physician documentation leaders
Quality managers
EMR staff
Intended audience:
Clinical documentation managers
Nurse managers
Clinicians/managers who document in the patient record
Coders
Case managers
Case Mix managers
Compliance reviewers and managers
Health information managers
Physician documentation leaders
Quality managers
EMR staff
CDI-Cast Self-assessment:
Assess your program by answering a few key questions that will be provided at the end of the session. Use your responses to improve your current CDI program.
Q&A:
You can submit your questions on the CDI-Cast Web site. We will address as many of the questions as possible and post responses on the Web site. Responses will only be available for CDI-Cast subscribers to view.
Take-aways
Apply results of your program self-assessment
Pilot the seven criteria for HQCD training with a small group of physicians
Use the CAMP™ Method results to improve your training
Incorporate the mastering components of the CAMP Method into your current training program