Clinical Documentation Zuri March 28 2023
Clinical Documentation Zuri March 28 2023
Clinical Documentation Zuri March 28 2023
Communication
Accountability
Legislative Requirements
Quality Improvement
Research
Funding and Resource Management
The organization has a planned Continuous Quality Improvement Presence of Quality Improvement
systematic organization-wide Program Program
approach to process design and
performance measurement,
assessment and improvement
Appropriate professionals Nurses make use of nursing Charts have nurses’ notes
perform coordinated and process in the care of patients Presence of Nursing manual and
sequenced patient assessment to properly utilized Kardex
reduce waste and unnecessary
repetition
Medicines are administered in a Medicines are administered in a All medicines are administered
standardized and systematic timely, safe, appropriate and observing the five (5) R’s of
manner. Diagnostic examinations controlled manner medication which are:
appropriate to the provider 1. Right patient
organizations service capability 2. Right Medication
and usual case mix are available 3. Right dose
and are performed by qualified 4. Right route
personnel. 5. Right time
STANDARD CRITERIA INDICATOR
Appropriate professionals Previously obtained information is All patient charts have progress
perform coordinated and reviewed at every stage of the notes by doctors and other health
sequenced patient assessment to assessment to guide future professional
reduce waste and unnecessary assessments
repetition
The discharge plan is a part of Discharge plans for patients to All charts have discharge plans
the patients care plan and is ensure continuity of care
documented in the patients’
chart
Clinical records are readily Electronic Medical records All general and specialty hospitals
accessible to facilitate patient are mandated to comply with the
care are kept confidential and EMR implementation.
safe, and comply with all EMR – e-claims, primary care
Philippine Health Records Standard
include:
Licensing Standards as defined in Administrative
Order 2012-0012
International Health record Standard as defined
by the Joint commission International
Accreditation Standards
PhilHealth Benchbook
International Organization for Standardization
(ISO 9001:2015)
Other regulatory/mandatory policies;
RA 10173 – data privacy act of 2021
RA 11223 Universal Health Care Act
AO 2013-005 National Policy on the unified
disease registry system of DOH
RA 9470 National Archives Act of the
Philippines 2007
The contents of Patient’s chart:
Face sheet
Informed consent
History of the physical examination
Doctor’s order
Nurses notes
TPR sheet
Laboratory report
Imaging reports
Maternal record with partograph
Newborn record and maturity rating
The contents of Patient’s chart:
Medication/treatment record
Operative and anesthesia record
Record of interdepartmental referral/consultation
to other physicians, including notes
Record of referral or transfer of patient to other
facility/service/doctor including notes
Discharge summary
Clinical Abstract
Advance directive
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1. There must be a health record for each
patient confined/treated in the healthcare
facility.
2. Documentation in the health record must
General Guidelines on
Documentation of
reflect the patient’s physical condition,
Health Records: and the orders and care provided from
admission to discharge.
3. Documentation in the health record must
reflect the patient’s physical condition,
and the orders and care provided from
admission to discharge.
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4. Documentation must reflect observation
and must be objective and non
judgmental.
General Guidelines on 5. There must be a standard format for
Documentation of health record documentation by the
Health Records:
physician and other interdisciplinary
team members who participated in the
care of the patient.
6. All documents must be legible and
written in ink or typewritten.
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01 02 03
In order to correct an
Draw a single Affix the Write the
error, the following line through the attending correct entry
shall be done: information to physician’s near the
be corrected or initial, date and information to
changed time be corrected
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13.In cases where the patient wants some
data corrected especially on the
demographic/sociological data, the
correction should not be done on the
General Guidelines on
Documentation of
original entry, but shall appear as an
Health Records: amendment only.
14.The health records must contain all original
copies of examination results, operations
and other required forms.
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15. The inpatient health record must be completed
and it must include the following forms properly
accomplished, signed and dated.
General Guidelines on Patient’s data sheet - (name, address and other social data)
Documentation of
Health Records:
Admitting and final diagnosis – description of any operation
and procedures performed
i. Anesthesia record
15. The inpatient health
j. Report of an operation – authenticate a pre-operative diagnosis
record must be completed before a surgery. (all findings, surgical technique, description f any
and it must include the tissue removed and post-operative diagnosis.
following forms properly
accomplished, signed and k. Nurses notes – observations, treatment given, response to
treatment and any unusual occurrences.
dated.
l. Certificate of Live birth, Fetal and Death certificate
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Implementing a Clinical Documentation Improvement Program
Accurate claim submission, favorable audit results, a healthy revenue cycle, and better
health outcomes for the patient are all reasons to implement a CDI program. CDI can be
challenging if all parties involved in implementing a CDI program (physicians, administrators,
CDI specialists, and coding and billing staff) do not understand the purpose and process of CDI
and how each role is vital.
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5 Steps to Implement a Successful CDI Program
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5 Steps to Implement a Successful CDI Program
2.Decide how CDI reviews are selected.
inpatient CDI program may have EHR system alerts when a patient is admitted with
certain complicated diagnoses.
outpatient program may have a policy to randomly select a sample of charts to review or
generate reports of certain diagnoses to perform more targeted reviews.
3.Establish clinical standards. establish a decision-tree protocol ( clinical
pathways)
4.Review the reviews
is to evaluate not only the flow and results of the CDI program
determine whether the process follows ethical standards.
Use an analysis rubric to identify areas of improvement, nonbeneficial activities, and the
successful results of the program. Look for both the good and the bad practices
5.Collaborate
CDI specialist and the medical coder
CDI specialist and the physician —
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Personnel – Medical Records Officer
Bachelor’s Degree
Training in ICD-10
Training in Medical Records Management
CDI Personnel – Medical Records Officer
Bachelor’s Degree
Training in ICD-10
Training in Medical Records Management