Healthcare Documentation

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Registries for Evaluating Patient Outcomes

Author : Agency for Healthcare Research and Quality/AHRQ
Publisher : Government Printing Office
ISBN 13 : 1587634333
Total Pages : 396 pages
Book Rating : 4.5/5 (876 download)

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Book Synopsis Registries for Evaluating Patient Outcomes by : Agency for Healthcare Research and Quality/AHRQ

Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Hillcrest Medical Center: Healthcare Documentation and Medical Transcription

Author : Patricia Ireland
Publisher : Cengage Learning
ISBN 13 : 9781305583924
Total Pages : 396 pages
Book Rating : 4.5/5 (839 download)

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Book Synopsis Hillcrest Medical Center: Healthcare Documentation and Medical Transcription by : Patricia Ireland

Download or read book Hillcrest Medical Center: Healthcare Documentation and Medical Transcription written by Patricia Ireland and published by Cengage Learning. This book was released on 2017-01-27 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: This innovative text uses a simulation approach to give readers interested in healthcare documentation and medical transcription careers a working knowledge of medical reports common in both acute and chronic care settings. Readers have access to transcription of 107 patient medical reports, including 56 new reports exclusive to the Eighth Edition. This edition also features 20 new speech recognition technology/medical editing (SRT) reports, as well as information on electronic health records (EHRs), quality assurance (QA), and scribes to keep readers up-to-date on the latest advances in the field. Organized by body system, the text includes full-color anatomy and physiology illustrations to make medical terminology easier to master. In addition, the authors have included a review of proper formatting, grammar, and style in accordance with the AHDI's BOOK OF STYLE, and a master glossary list compiles key terms in one section for convenient study and quick reference. Important Notice: Media content referenced within the product description or the product text may not be available in the ebook version.

Advanced Medical Transcription

Author : Laura Bryan
Publisher : Prentice Hall
ISBN 13 : 9780138014131
Total Pages : 0 pages
Book Rating : 4.0/5 (141 download)

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Book Synopsis Advanced Medical Transcription by : Laura Bryan

Download or read book Advanced Medical Transcription written by Laura Bryan and published by Prentice Hall. This book was released on 2013 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Advanced Medical Transcription bridges the gap between textbook medical terminology and "doctor speak." Fostering critical thinking and listening skills, this text demonstrates how foundational knowledge of physiology and disease processes combined with contextual clues can help decipher difficult dictation, discriminate sound-alike words and phrases, guide research efforts, and efficiently produce accurate documentation. The text's unique approach to terminology places an emphasis on medical phrases and medical lingo as opposed to individual terms. Exercises and activities throughout each chapter use authentic dictation from acute-care and ambulatory settings and cover a variety of medical specialties and accents.

Clinical Practice Guidelines We Can Trust

Author : Institute of Medicine
Publisher : National Academies Press
ISBN 13 : 030921646X
Total Pages : 217 pages
Book Rating : 4.3/5 (92 download)

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Book Synopsis Clinical Practice Guidelines We Can Trust by : Institute of Medicine

Download or read book Clinical Practice Guidelines We Can Trust written by Institute of Medicine and published by National Academies Press. This book was released on 2011-06-16 with total page 217 pages. Available in PDF, EPUB and Kindle. Book excerpt: Advances in medical, biomedical and health services research have reduced the level of uncertainty in clinical practice. Clinical practice guidelines (CPGs) complement this progress by establishing standards of care backed by strong scientific evidence. CPGs are statements that include recommendations intended to optimize patient care. These statements are informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options. Clinical Practice Guidelines We Can Trust examines the current state of clinical practice guidelines and how they can be improved to enhance healthcare quality and patient outcomes. Clinical practice guidelines now are ubiquitous in our healthcare system. The Guidelines International Network (GIN) database currently lists more than 3,700 guidelines from 39 countries. Developing guidelines presents a number of challenges including lack of transparent methodological practices, difficulty reconciling conflicting guidelines, and conflicts of interest. Clinical Practice Guidelines We Can Trust explores questions surrounding the quality of CPG development processes and the establishment of standards. It proposes eight standards for developing trustworthy clinical practice guidelines emphasizing transparency; management of conflict of interest ; systematic review-guideline development intersection; establishing evidence foundations for and rating strength of guideline recommendations; articulation of recommendations; external review; and updating. Clinical Practice Guidelines We Can Trust shows how clinical practice guidelines can enhance clinician and patient decision-making by translating complex scientific research findings into recommendations for clinical practice that are relevant to the individual patient encounter, instead of implementing a one size fits all approach to patient care. This book contains information directly related to the work of the Agency for Healthcare Research and Quality (AHRQ), as well as various Congressional staff and policymakers. It is a vital resource for medical specialty societies, disease advocacy groups, health professionals, private and international organizations that develop or use clinical practice guidelines, consumers, clinicians, and payers.

Legal, Ethical, and Practical Aspects of Patient Care Documentation

Author : Ronald W. Scott
Publisher : Jones & Bartlett Publishers
ISBN 13 : 0763799106
Total Pages : 296 pages
Book Rating : 4.7/5 (637 download)

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Book Synopsis Legal, Ethical, and Practical Aspects of Patient Care Documentation by : Ronald W. Scott

Download or read book Legal, Ethical, and Practical Aspects of Patient Care Documentation written by Ronald W. Scott and published by Jones & Bartlett Publishers. This book was released on 2013 with total page 296 pages. Available in PDF, EPUB and Kindle. Book excerpt: Fourth Edition, is the only text to integrate coverage of the legal responsibilities of rehabilitation professionals with basic, essential advice on how to effectively document patient care activities from intake through discharge. This resource thoroughly covers the basics of documentation and includes many exemplars, cases, and forms, as well as a sample abbreviations used in rehabilitation settings. This book covers all the bases from ethics, to practical aspects of patient care documentation, to relevant and salient legal implications and illustrative case examples that will help students excel in practice.

Guide to Clinical Documentation

Author : Debra D Sullivan
Publisher : F.A. Davis
ISBN 13 : 0803669992
Total Pages : 416 pages
Book Rating : 4.8/5 (36 download)

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Book Synopsis Guide to Clinical Documentation by : Debra D Sullivan

Download or read book Guide to Clinical Documentation written by Debra D Sullivan and published by F.A. Davis. This book was released on 2018-07-25 with total page 416 pages. Available in PDF, EPUB and Kindle. Book excerpt: Understand the when, why, and how! Here’s your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward ‘how-to’ approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You’ll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.

The Clinical Documentation Improvement Specialist's Handbook, Second Edition

Author : Heather Taillon
Publisher : HC Pro, Inc.
ISBN 13 : 1601467753
Total Pages : 171 pages
Book Rating : 4.6/5 (14 download)

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Book Synopsis The Clinical Documentation Improvement Specialist's Handbook, Second Edition by : Heather Taillon

Download or read book The Clinical Documentation Improvement Specialist's Handbook, Second Edition written by Heather Taillon and published by HC Pro, Inc.. This book was released on 2011-01-21 with total page 171 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards

The CDI Guide for Home Health and Hospice

Author : Tricia A. Twombly
Publisher :
ISBN 13 : 9781683086017
Total Pages : 0 pages
Book Rating : 4.0/5 (86 download)

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Book Synopsis The CDI Guide for Home Health and Hospice by : Tricia A. Twombly

Download or read book The CDI Guide for Home Health and Hospice written by Tricia A. Twombly and published by . This book was released on 2017-07-20 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: The CDI Guide for Home Health and Hospice addresses the unique challenges of both home health and hospice agencies in a practical fashion. Its expert authors and reviewers--veterans of the postacute field--provide tips on educating and querying physicians who don't work for you, choosing home health and hospice areas to focus on, and selecting agency members for your CDI program's steering committee.

Getting Your Affairs in Order

Author :
Publisher :
ISBN 13 :
Total Pages : 6 pages
Book Rating : 4.:/5 (319 download)

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Book Synopsis Getting Your Affairs in Order by :

Download or read book Getting Your Affairs in Order written by and published by . This book was released on 1988 with total page 6 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Successful Collaboration in Healthcare

Author : Colleen Stukenberg
Publisher : CRC Press
ISBN 13 : 1439812934
Total Pages : 138 pages
Book Rating : 4.4/5 (398 download)

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Book Synopsis Successful Collaboration in Healthcare by : Colleen Stukenberg

Download or read book Successful Collaboration in Healthcare written by Colleen Stukenberg and published by CRC Press. This book was released on 2010-01-27 with total page 138 pages. Available in PDF, EPUB and Kindle. Book excerpt: This critically acclaimed work makes the case for collaboration and shows that it can be greatly enhanced with conscious understanding and systematic effort. As a healthcare specialist who has worn many hats from direct care giver to case manager to documentation specialist, Colleen Stukenberg is able toShow how to build trust and communicat

Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies

Author : OECD
Publisher : OECD Publishing
ISBN 13 : 9264805907
Total Pages : pages
Book Rating : 4.2/5 (648 download)

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Book Synopsis Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies by : OECD

Download or read book Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies written by OECD and published by OECD Publishing. This book was released on 2019-10-17 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.

Legal Aspects of Documenting Patient Care

Author : Ronald W. Scott
Publisher : Jones & Bartlett Learning
ISBN 13 : 9780834216303
Total Pages : 248 pages
Book Rating : 4.2/5 (163 download)

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Book Synopsis Legal Aspects of Documenting Patient Care by : Ronald W. Scott

Download or read book Legal Aspects of Documenting Patient Care written by Ronald W. Scott and published by Jones & Bartlett Learning. This book was released on 2000 with total page 248 pages. Available in PDF, EPUB and Kindle. Book excerpt: This Second Edition Of Our Easy-To-Use Reference Takes A Risk Management Approach To Patient Care Documentation. It Shows Clinicians From A Wide Variety Of Disciplines How To Be Objective, Precise, Unambiguous, And Timely When Documenting Treatment-Related Matters. The Content Is Written In Straightforward Lay Language And Includes Sample Documentation Forms. The New Edition Includes Information On Computerized Documentation; Coverage Of Telehealth Issues; Updates On JCAHO, CARF, And NCQA Accreditation; And Documentation Problems Specific To Non-Hospital And Managed Care Settings.

Documentation for Health Records

Author : Cheryl Gregg Fahrenholz
Publisher :
ISBN 13 : 9781584265542
Total Pages : 488 pages
Book Rating : 4.2/5 (655 download)

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Book Synopsis Documentation for Health Records by : Cheryl Gregg Fahrenholz

Download or read book Documentation for Health Records written by Cheryl Gregg Fahrenholz and published by . This book was released on 2017 with total page 488 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Clinical Documentation Specialist - The Comprehensive Guide

Author : VIRUTI SHIVAN
Publisher : Viruti Satyan Shivan
ISBN 13 :
Total Pages : 232 pages
Book Rating : 4./5 ( download)

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Book Synopsis Clinical Documentation Specialist - The Comprehensive Guide by : VIRUTI SHIVAN

Download or read book Clinical Documentation Specialist - The Comprehensive Guide written by VIRUTI SHIVAN and published by Viruti Satyan Shivan. This book was released on with total page 232 pages. Available in PDF, EPUB and Kindle. Book excerpt: Dive into the essential world of clinical documentation with "Clinical Documentation Specialist - The Comprehensive Guide," a pivotal resource designed for healthcare professionals committed to excellence in patient care through meticulous record-keeping. This guide offers a deep dive into the principles of accurate and compliant medical documentation, highlighting its critical role in ensuring optimal patient outcomes and the seamless operation of healthcare systems. With an emphasis on practical strategies, real-world applications, and the latest compliance standards, this book serves as an invaluable tool for both aspiring and experienced clinical documentation specialists. By focusing on enhancing communication between healthcare providers and supporting the delivery of high-quality care, it addresses the challenges and complexities of modern medical documentation practices. Without relying on images or illustrations for clarity, the guide stands out for its comprehensive coverage and insightful analysis, making it a unique addition to the professional library of healthcare providers. It transcends basic instructional material by weaving in theoretical knowledge with actionable advice, empowering readers to navigate the nuanced landscape of healthcare documentation with confidence. The absence of visual elements is more than compensated for by the depth of knowledge and the engaging writing style, ensuring that readers are equipped with the knowledge and skills necessary to make a significant impact in their roles as guardians of patient information and care continuity.

Patient Safety and Quality

Author : Ronda Hughes
Publisher : Department of Health and Human Services
ISBN 13 :
Total Pages : 592 pages
Book Rating : 4.:/5 (318 download)

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Book Synopsis Patient Safety and Quality by : Ronda Hughes

Download or read book Patient Safety and Quality written by Ronda Hughes and published by Department of Health and Human Services. This book was released on 2008 with total page 592 pages. Available in PDF, EPUB and Kindle. Book excerpt: "Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

Clinical Documentation Reference Guide - First Edition

Author : AAPC
Publisher : AAPC
ISBN 13 : 1626889791
Total Pages : 13 pages
Book Rating : 4.6/5 (268 download)

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Book Synopsis Clinical Documentation Reference Guide - First Edition by : AAPC

Download or read book Clinical Documentation Reference Guide - First Edition written by AAPC and published by AAPC. This book was released on 2020-03-12 with total page 13 pages. Available in PDF, EPUB and Kindle. Book excerpt: It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.

Unequal Treatment

Author : Institute of Medicine
Publisher : National Academies Press
ISBN 13 : 030908265X
Total Pages : 781 pages
Book Rating : 4.3/5 (9 download)

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Book Synopsis Unequal Treatment by : Institute of Medicine

Download or read book Unequal Treatment written by Institute of Medicine and published by National Academies Press. This book was released on 2009-02-06 with total page 781 pages. Available in PDF, EPUB and Kindle. Book excerpt: Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received. In Unequal Treatment, a panel of experts documents this evidence and explores how persons of color experience the health care environment. The book examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients' and providers' attitudes, expectations, and behavior are analyzed. How to intervene? Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas. The committee highlights the potential of cross-cultural education to improve provider-patient communication and offers a detailed look at how to integrate cross-cultural learning within the health professions. The book concludes with recommendations for data collection and research initiatives. Unequal Treatment will be vitally important to health care policymakers, administrators, providers, educators, and students as well as advocates for people of color.