Improving CDI Programs and Alternative Methods and Solutions for Documenting a Clinical Encounter

Agenda

The Role of the Medical Record- Going Beyond Reimbursement

• The Medical Record Serves a Myriad of Purposes Beyond a Repository for Physician Documentation That Supports Coding, Billing and Reimbursement. Learn How the Record Represents a Wide Array of Purposes Supporting and Facilitating Quality Focused Patient Centered Patient Care, All Fundamentally Dependent Upon Complete and Accurate Clinical Documentation That Best Describes, Shows and Tells the Patient Story
• Understand How the Electronic Health Record Has Degraded the Quality and Value of the Medical Record and What Steps Can Be Taken to Drive Clinical Documentation Excellence Through Deployment of Strategies That Engage Physicians
• Plan, Develop and Organize and Implement an Effective Strategy to Enhance the Quality and Completeness of the Medical Record, Utilizing a Team-Based Approach Incorporating All Stakeholders in a Multidisciplinary Approach on Behalf of the Patient and Quality Achieved Cost Effective Patient Outcomes

Addressing Insufficiencies in Physician Documentation- Expanding Traditional CDI Approaches

• Embrace Change in Current CDI Programs- Transform, Redesign, Reposition and Reengineer Present CDI Programs as the Backbone for Achieving Clinical Documentation Excellence
• Outline and Discuss Key Elements of an Effective CDI Program Necessary for Successful Transformation That Creates a Vision That Inspires Physicians, the Care Team and All Relevant Health care Stakeholders to Work Together to Consistently Achieve Clinical Documentation Excellence
• Share Two CDI Program Development Case Studies, Highlighting Operational Processes and Redesign Required as Well as Key Performance Indicators Established and Implemented to Achieve Solid Performance in Clinical Documentation Excellence That Was Sustainable Over Time

Defining Best Practice Standards and Principles of Physician Documentation for Effective Patient Care Communication

• Define Best Practice Standards and Principles of Physician Documentation That Communicates Patient Care Effectively Using Real Case Studies Outlining Insufficient Versus Sufficient Documentation
• How CDI Programs Can Incorporate Best Practice Standards and Principles of Clinical Documentation Into Present Day CDI Programs With a Focus Upon Physician Learnings and Teachings Extending Beyond the Traditional Query Process
• The Physician Advisor as the Leader and Change Agent in Transforming Current CDI Efforts From Reimbursement to Quality and Completeness of Documentation- It Is All About the Patient

Credits

Faculty

Douglas Cutler

Northern Arizona Hospitalists

• Conducts webinars on clinical documentation and its importance to the practicing physician
• Continues to work as a hospitalist in Arizona; has been a regional medical director of a multistate Hospitalist Group as well as physician advisor in Phoenix
• Physician Professional Development: Bridging the gap between the new work reality and self-satisfaction
• Honorable discharge USAF as Major
• Member of the Society of Hospital Medicine and American College of Physician Advisors
• B.S. degree and M.D. degree, University of Michigan, Residency at Wright Patterson USAF Base
• Can be contacted at 623-341-8813 or [email protected]

Glenn Krauss, VBBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CD

Glenn Krauss, VBBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CDI, C-DAM, C-P

• Founder of Core-CDI.com
• Experience includes over years of progressive practical hands-on experience in clinical coding & documentation improvement, subscribing to the philosophy that quality of medical record documentation strongly correlates with overall quality of care & the overall achievement of a high performing revenue cycle
• Well-recognized and respected subject matter expert in the revenue cycle with an emphasis & focus upon collaborating & working closely with physicians in promoting, advocating for, educating & achieving sustainable improvement in clinical documentation that accurately reflects & reports the communication of fully informed coordinated patient care
• Experience in implementing various electronic health records including Cerner, Meditech, Athena, and Epic
• Has been instrumental in helping client physicians develop documentation templates to help streamline the EHR charting process as well as developed model documentation policies governing the Copy & Paste functionality within the EHR. Glenn works with Information Technology departments within hospitals and medical centers to develop extensive EHR training modules for physicians to take and become proficient in utilizing the EHR, navigating and controlling the documentation within the EHR versus the EHR controlling the documentation
• Frequently presents to many hospital associations, AHIMA and ACDIS chapters, and the American College of Physician Advisors
• Member of AHIMA, ACDIS, and HFMA
• B.B.A. Degree in management, Hofstra University in Hempstead, New York
• Can be contacted at 603-303-3337 or [email protected]