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Search Results for Documentation
Abstract Number: 222
Hospital Medicine 2018; April 8-11; Orlando, Fla.
Background: Mortality is the first quality metric reported by CMS, and historically a key measure for evidence based medicine since the 1800’s. THINK: John Snow removing the handle from the Broad street well pump to reduce cholera deaths Ignaz Semmelweis demonstrating washing hands reduced puerperal fever and death. Mortality rates are risk adjusted […]
Abstract Number: 223
Hospital Medicine 2018; April 8-11; Orlando, Fla.
Background: Since the advent of Electronic Health Record(EHR) and subsequent workload of clinical documentation, Hospital Medicine physicians are finding themselves spending more time in front of the computer and less with their patients. The implementation of EHR was intended to help physicians improve productivity and quality, however, data shows we are spending up to 25% […]
Abstract Number: 229
SHM Converge 2023
Background: The importance of accurate patient documentation for effective medical communication and financial compensation is well-documented. However, appropriate medical billing based on medical documentation is not emphasized in graduate medical education. We performed a review and analysis of resident charting errors during inpatient rotations to improve documentation and billing skills. Methods: A retrospective study was […]
Abstract Number: 235
SHM Converge 2023
Background: There is no formal curriculum for medical students, residents or advanced practitioner students on appropriate clinical documentation improvement (CDI). As the primary documenters for medical records, several studies have shown benefit in billing, coding and hospital metrics with trainee education [1-2]. Despite this, there remains a scarcity of education on documentation for residents and […]
Abstract Number: 238
SHM Converge 2023
Background: The importance of accurate patient care records for effective communication and medical education is well documented. However, medical documentation as a tool for financial compensation is not emphasized in graduate medical education. We performed a review and analysis of resident charting errors during inpatient rotations to determine the potential revenue loss and economic impact. […]
Abstract Number: 239
Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.
Background: The original goal of progress notes is to provide a concise, up-to-date reflection of the patient’s condition and the provider’s thought processes. Electronic health records (EHRs) allow physicians to supplement traditional manual data entry with copied or imported text in these notes. However, this increases the risk of including outdated, inaccurate, or unnecessary information, […]
Abstract Number: 248
SHM Converge 2023
Background: A problem list serves as a central place for hospital-based clinicians to obtain a comprehensive and concise view of the patient’s active medical conditions. Use of the hospital problem list has many potential benefits: it provides a mental model of patient’s health status; streamlines the documentation process; makes chart review more efficient; facilitates communication […]
Abstract Number: 249
Hospital Medicine 2018; April 8-11; Orlando, Fla.
Background: Hospitalists have an increasing role in caring for patients with advanced illness. Due to time constraints, lack of experience and the sensitivity of the topic, it is challenging for Hospitalists to engage in adequate conversations regarding advanced care planning. Moreover, when these conversations do occur, documentation of Advanced Directives and Code Status is frequently […]
Abstract Number: 253
SHM Converge 2023
Background: Many hospitalized adults arrive with pre-existing malnutrition, which is associated with high risk of adverse outcomes. As such, malnutrition is a common variable in cost and quality risk adjustment models based on hospital discharge diagnosis codes. Hospital dietitians assess patients for malnutrition and generally document the details of their evaluations. However, coding professionals cannot […]
Abstract Number: 256
Hospital Medicine 2020, Virtual Competition
Background: Hospitals are nationally ranked on the basis of comparisons of quality of care, mortality, readmissions and health care associated infections.1 Center for Medicare and Medicaid Services (CMS) looks at these top 6 illnesses; stroke, pneumonia, heart failure, chronic obstructive pulmonary disease, acute myocardial infarction and coronary artery bypass graft (CABG) to compare hospital’s specific […]