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September Tuesday Talks

What You May Not Know About Documentation

 

Stacey Sever, BSN, RN
Clinical Documentation Specialist

With the introduction of EHRs, documentation has certainly changed in its processes and retrieval of information for analyses. Along with it, there has been an increased level of documentation burden. According to Hakes & Whittington, 2008, the current documentation burden in nursing is high and is a major source of job dissatisfaction among direct care nurses.

This presentation will discuss how documentation has a wide reaching effect not only on direct patient care but also behind the scenes in the areas of data collection and quality measures as well as current and future reimbursement.

Objectives:
-Demonstrate an understanding of how specific and accurate documentation affects risk adjustment, quality initiatives, patient safety and hospital reimbursement 
-Demonstrate an understanding of the role of Clinical Documentation team and how they work together with the coding team to ensure an accurate reflection of patient diagnoses.
-List examples on how nursing documentation has a direct and indirect role on capturing the patient’s condition during a hospital admission 
-Understand the effects of poor documentation has on mortality statistics, financial penalties, and future reimbursement pay schedules
-Understand the RAC and Appeal process for claim determinations

RSVP to dani@aknurse.org to let us know you're coming!

 

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