Patient referral form template, Documentation is your best friend and it’s the key to reimbursement. However, if your documentation isn’t up to snuff, it might be your worst enemy. Your anesthesia coding can suffer and you may even face a denial or confront OIG’s scrutiny. Before you pass the documentation for your coder or head to get a CPT code search, 2013yourself, be sure that all the necessary facts have been in place and in order. Correct any error, or reevaluate your anesthesiologists and find additional clarification, if need be.
Both the welfare of the patients and the reputation of the institution are at risk by neglecting some of the aspects that are important in allowing smooth work flow. To better achieve the objective of providing superb medical services, it is required to have an effective clinical documentation improvement program to ensure the standard of health care records as they are required to be precise and free of any error.
Medical documentation not just involves records and details related to medical services offered to the patients. Medical records may also be legal documents, billing or insurance requirements, claims, and other administrative records which are most likely regulated by several standards and policies. Neglecting a few of these aspects will certainly result to legal problems and medical failures. This will not only undermine the job of the personnel responsible but also the welfare of the patients involved. You can imagine how sensitive data is at any medical institution. A lot of medical complications happened due to misunderstanding about the right process that should have been clarified clearly on the medical records. There are even cases of deaths due to improper documentation of health records.
Maybe this is why clinical documentation improvement programs have been implemented not only to promote high excellent healthcare services but also to protect the patients out of malpractices and health care failures. The regulations are put to make each and every personnel accountable to record the actual and real medical condition of a patient in relation to the sort of services that were provided.
You can practically say that these programs are developed to safeguard human life as they are concentrated on types of information that can have a fantastic impact to the welfare of a person. It can be very frustrating to know that you just lost a loved one because a hospital is not capable enough to supply the maximum quality of health care services. By applying clinical documentation improvement programs, you can say that you’ve tried your best to promote human life and well being.