Tag Archives: Clinical Documentation

Documentation to Prove Medical Necessity for Urology Procedures

Accurate clinical documentation that supports medical necessity is essential for getting proper payments for urology procedures. Medical necessity of a service is defined as an overarching criterion for payment apart from individual requirements specified for a CPT code. You should … Continue reading

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EHR Access Significantly Impact Radiology Decision Making

Most radiology departments have begun to transition from paper-based imaging requests to electronic orders originating in an EHR system with a view to streamlining their workflow. Access to EHRs can have a significant impact on radiology decision making. Electronic record … Continue reading

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Acrostic for Quality Pediatric Post-take Ward Rounds Documentation

It is very important to maintain quality and accuracy when documenting pediatric post-take ward rounds (PTWR) since care is evaluated, and coordinated care plans are formulated during this time. This documentation task often left to junior doctors is quite challenging … Continue reading

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PDCA Quality Principles for Clinical Documentation

As the healthcare system in the U.S is shifting from paper-based to electronic health records (EHRs), it has become very important to focus on the quality of patients’ records for improved and consistent patient safety outcomes. This has made the … Continue reading

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Why Accurate Documentation is Critical for Diagnosing Parkinson’s Disease

Though PET and DAT scans may aid the diagnosis of Parkinson’s disease or PD, it cannot differentiate PD and Parkinsonian subtypes. Clinical findings are still used to diagnose PD. However, a study published in the June issue of the Neurology … Continue reading

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EHR Deficiencies in HIMSS Survey and the Need for Medical Transcriptionists

Most providers are transitioning to EHR technology owing to the EHR incentive program, and they must be sure of their clinical documentation integrity. A 2014 survey by the Healthcare Information and Management Systems Society (HIMSS) found severe deficiencies with EHR … Continue reading

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A More Comprehensive Approach to Address SRT Challenges

Speech recognition technology (SRT) is being increasingly adopted in clinical documentation. While only a small percentage of providers use this technology in self-editing (front-end) mode, the use of back-end SRT system is growing rapidly within the healthcare field. Though many providers … Continue reading

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Collaborative Depression Care for Pregnant Women, What’s the Role of Documentation?

Untreated depression during pregnancy can lead to poor nutrition, drinking, smoking, and suicidal behavior in mothers and also result in premature birth of the baby, low birth weight and developmental problems. A study published in Obstetrics & Gynecology (June 2014 … Continue reading

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Electronic Documentation and the Role of Medical Transcriptionists

Though paper-based clinical documentation is transitioning to electronic clinical documentation, a human interface is still relevant to make the technology work optimally and that human interface already exists in the form of skilled healthcare documentation specialists as per the Association … Continue reading

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Why Accurate Clinical Documentation Is Essential for Bariatric Surgery

Weight loss surgery or bariatric surgery is very effective for severe and medically complicated obesity with associated risks, even death. This treatment is used when less invasive weight loss methods fail. However, there are several risks associated with the surgery itself such as blood clot, excessive bleeding, lung or breathing problems and so on. Continue reading

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