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PubMedDate not supplied

The high point of efforts to improve access to health care by "documentation".

The set of articles of which this article is a part has documented the tension between the advocates and the opponents of government intervention in the American health care system. This article will focus on a chapter of American health care history that is almost forgotten and has still never been told in its entirety. The story of the Committee on the Costs of Medical Care (CCMC), which existed from 1927 to 1933, represents the apogee of the factual approach effort to changing health care delivery in America.

Delivery of Health Care↗
PubMed1993

Coding, documentation and dollars.

Physicians would like to get reimbursed for the services they perform. Unfortunately, many of them are not very good at documenting what they do. The result is that physicians are being reimbursed far less than what they should be or are being asked to refund reimbursement for services they cannot substantiate. The financial impact to the physician's practice can be enormous. For many years, physicians have viewed HIM professionals as adversaries. There now exists the opportunity for HIM professionals to become allies with physicians by helping them obtain and maintain the reimbursement they are entitled to. Physicians have the need, and HIM professionals have the knowledge and skill. It is up to our profession to show them what we can do.

Abstracting and Indexing↗
PubMed1993

Documentation of clinical and cost-saving pharmacy interventions in the emergency room.

Hospital pharmacists have shown clearly their benefit in patient care by intervening to improve the drug use process. In this era of cost containment, hospital administrators are likely to fund only those programs that clearly improve patient care or reduce costs. To demonstrate the impact on a hospital budget and to justify a position or service, documentation of improvement and generation of a cost-savings report is essential. This article discusses the types and methods of clinical and cost-saving interventions that are made in a busy inner city university trauma center's emergency department, and the methods by which our data are collected.

Clinical Pharmacy Information Systems↗
PubMed1992

Documenting the clinical interventions of pharmacists.

The need to justify continued and expanded clinical services persists in the current climate of concern over the high costs of health care; thus, documentation of the clinical interventions of pharmacists is vital. Time is a limited commodity, and an intervention reporting system must be as efficient as possible. A system that can be integrated into departmental and institutional quality assurance activities is a necessity; the capability of sharing the information with other hospital committees and departments is also an important consideration.

Adverse Drug Reaction Reporting Systems↗
PubMed1992

Using clinical intervention documentation.

The clinical intervention reporting system that we are using at our facility provides pharmacy management, hospital management, and the quality improvement committee with valuable information. Pharmacy management can use the interventions to motivate, train, and evaluate pharmacists, as well as justify full-time equivalent employees. Hospital management can use the data in the budgeting process, in physician credentialing, and as a part of the medical center's cost containment efforts. The quality improvement committee can use the data in drug selection for DUEs, as well as for information in clinical privileging. Now pharmacy can say with confidence, "We are documenting it; we are doing it."

Clinical Pharmacy Information Systems↗
PubMed1992

Documentation and assessment of pharmacist-initiated drug therapy interventions.

In conclusion, the development of an efficient system to document pharmacist-initiated drug therapy interventions has been successful. The system has been incorporated into the pharmacy quality assurance program and is being used to evaluate the provision of pharmaceutical care. Finally, the system has been incorporated into the clinical services drug-use evaluation program and is being used to evaluate individual physician prescribing practices.

California↗
PubMedDate not supplied

The quality of patient care documentation.

Medical transcriptionists can attest to the accuracy of their transcription, but they cannot attest to the accuracy of patient or provider identification. The quality of patient care documentation can only be attested to by provider review and signature, i.e., through authentication.

Authorship↗
PubMed1995

Medicaid program; rescission of the guidelines for documenting Medicaid recipient access to immunizations under the Vaccines for Children (VFC) Program--HCFA. Notice.

This notice rescinds the guidelines that we published in the Federal Register on October 3, 1994, that required States to document equal access to immunizations for Medicaid children if States elected to use lower vaccine administration fees than the maximum charges that were published and applicable under the Vaccines for Children program. These guidelines are rescinded in response to public comments on the October 3, 1994 notice. States indicated that there were numerous problems regarding the collection of useable data.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1992

Documenting investment policy boosts safety, returns.

The process and responsibility for a healthcare organization's investment decisions should be clearly documented in an investment policy. Any investment policy should contain at least seven elements: how investments relate to the organization's mission; responsibilities of involved parties; long- and short-term objectives; desired balance between return and risk; proportions of a portfolio held in stocks, bonds, and other investments; disposition of donated assets; desired investment reports; and the process for keeping the policy current.

Documentation↗
PubMed1995

Documentation of the first steps of pediatric pharmaceutical care in a county hospital.

Pediatric pharmaceutical care is still a new concept in the pharmacy profession. In our county institution with 35% of the beds reserved for pediatric patients, there existed no formal process for providing specialized pediatric pharmacy services. In an effort to rectify this situation, a study was conducted to determine the benefits of providing pharmaceutical services by having a clinical pharmacist round with physicians on a daily basis for 3 hours. All services provided were documented for 6 months and direct cost-savings were calculated. Five hundred four different interventions and services were provided, with over $7000 in savings. Because of these findings, the pharmacy and hospital administration agreed to provide a staff pharmacist to round in pediatrics on a regular basis. This approach is considered to be more cost effective than using a clinical pharmacist for daily rounds.

Child↗
PubMedDate not supplied

Winning performance improvement strategies--linking documentation and accounts receivable.

When the HIM department at The University of Texas Medical Branch set out to improve documentation and accounts receivable management, it established a plan that encompassed a broad spectrum of data management process changes. The department examined and acknowledged the deficiencies in data management processes and used performance improvement tools to achieve successful results.

Accounts Payable and Receivable↗
PubMed1996

Meeting European and US requirements for design and development documentation, Part II.

Part I of this series of articles provided a comparison of the European and the proposed United States (US) Food and Drug Administration (FDA) design control requirements. Since writing Part I, the US Good Manufacturing Practice (GMP) final rule has been published. This article will discuss the changes made to the design control requirements in the US final rule. It will also discuss some of the types of procedures and documentation that companies can develop to comply with the European and US design control requirements.

Documentation↗
PubMed1997

Improving clinician acceptance and use of computerized documentation of coded diagnosis.

After the Northwest Division of Kaiser Permanente implemented EpicCare, a comprehensive electronic medical record, clinicians were required to directly document orders and diagnoses on this computerized system, a task they found difficult and time consuming. We analyzed the sources of this problem to improve the process and increase its acceptance by clinicians. One problem was the use of the International Classification of Diseases (ICD-9) as our coding scheme, even though ICD-9 is not a complete nomenclature of diseases and using it as such creates difficulties. In addition, the synonym list we used had some inaccurate associations, contributing to clinician frustration. Furthermore, the initial software program contained no adequate mechanism for adding qualifying comments or preferred terminology. We sought to address all these issues. Strategies included adjusting the available coding choices and descriptions and modifying the medical record software. In addition, the software vendor developed a utility that allows clinicians to replace the ICD-9 description with their own preferred terminology while preserving the ICD-9 code. We present an evaluation of this utility.

Abstracting and Indexing↗
PubMed1999

[The clinical and legal characteristics of managing medical documentation in dental implantology].

Legislative basis of medical service is developing in Russia and implantation methods of treatment are introduced in practical dentistry; documents regulating legal relations between the patient and doctor (institution) in cases with treatment involving implantation are offered. The proposed clinical examinations can lay the basis for creation of a universal information network which will help develop the references for evaluating the efficacy of types and systems of implants and objectively study the causes of failures in dental implantology.

Dental Implantation↗
PubMed1988

Documentation of clinical interactions: quality of care issues and economic considerations in critical care pharmacy.

Pharmacists employed in the critical care area in a 350 bed, community-based, Class II trauma facility demonstrated cost savings through documentation of clinical interactions. Data collection took place between January 1, 1986 and December 31, 1986. Four areas of potential cost savings to the hospital were identified: 1) interactions that resulted in drug cost avoidance of $26,580 per year; 2) detection of excessive doses, toxic serum concentrations and electrolyte imbalances resulting in maximizing quality drug therapy; 3) unnecessary or inappropriate laboratory tests, which avoided $3930 in patient charges due to 80 fewer tests; 4) reduced inventory from the critical care area allowing $5209 in medication to be relocated. Under current prospective reimbursement programs, cost containment and quality care are of primary concern for pharmacy departments. The presence of a critical care satellite staffed by qualified pharmacists can provide these measures.

California↗
PubMed1986

Case-mix adjustments require tighter documentation.

Six states currently incorporate case-mix adjustments into their payment formulas for long-term care, and Medicare is likely to follow suit in the near future. Case-mix systems require facilities to keep detailed records on patients' functional abilities, medical conditions, daily progress, and treatment plans. Much of the information required is similar to the data that the Patient Care and Services (PaCS) survey program will collect and evaluate for the new Medicare and Medicaid certification process. Long-term care facilities must establish policies and procedures to accommodate the new requirements. Recommended steps include: Redesign medical record forms so that each patient's functional limitations and medical conditions can be documented. Design care plans so that they identify the patients' disabilities and medical problems, set realistic short- and long-term treatment goals, establish appropriate interventions, and designate the care giver responsible for each intervention. Focus progress notes on problem resolution. Replace medical care evaluation processes with a quality assurance program that determines whether care plans are followed and goals reached.

Diagnosis-Related Groups↗
PubMed1999

Accurate documentation, correct coding, and compliance: it's your best defense!

This article focuses on the need for physicians to maintain an awareness of regulatory policy and the law impacting the federal government's medical insurance programs, and to internalize and apply this knowledge in their practices. Basic information concerning selected fraud and abuse statutes and the civil monetary penalties and sanctions for noncompliance is discussed. The application of accurate documentation and correct coding principles, as well as the rationale for implementating an effective compliance plan in order to prevent fraud and abuse and/or minimize disciplinary action from government regulatory agencies, are emphasized.

Centers for Medicare and Medicaid Services, U.S.↗