Legal Issues in Inappropriate Documentation of Medical Information and Solutions

You are the director of health information services at a tertiary-care hospital. You and the director of emergency room services are jointly responsible for reporting instances of communicable disease, child abuse, and cancer to the appropriate state authority. You have just completed an audit of your institution’s reporting mechanism and discovered that the reporting requirements […]

Clinical documentation

Scenario: You have been asked to lead a Clinical Documentation Improvement (CDI) initiative. This small rural hospital is a 30-bed, fully paper-health dependent facility. Although the purchase and implementation of an Electronic Health Record (EHR) is not feasible at this time due to the accompanying price tag and other impacting factors, the hospital administrator recognizes […]

Abraham Lincoln University Documentation of Cardiac Assessment Report

You will perform a history of a cardiac problem that your instructor has provided you or one that you have experienced, and you will perform a cardiac evaluation. You will document your subjective and objective findings, identify actual or potential risks, Expert Solution Preview Introduction: As a medical professor, I have the responsibility of designing […]

Nursing Education Practicum Documentation, health and medicine homework help

Nursing Education Practicum Documentation Using the “Nursing Education Practicum Documentation (NEPD) Form,” write goals of what you will accomplish in this topic and how you will evaluate your accomplishment. Be sure to read the instructions (in blue font at the top of the columns on the first page) on how to use the form before […]

A clinical documentation improvement (CDI) specialist notices that one of the physicians from the cardiac catheter lab is now performing procedures in the operating room. Although this may be appropri

A clinical documentation improvement (CDI) specialist notices that one of the physicians from the cardiac catheter lab is now performing procedures in the operating room. Although this may be appropriate, the CDI specialist has worked in the facility a number of years and is not aware of any advanced training that would qualify this physician […]

A Typical Day as a Medical Coder and Biller Essay As a medical coder you will be responsible for reviewing patient documentation for encounters that has been added to an Electronic Health Record by a

A Typical Day as a Medical Coder and Biller Essay As a medical coder you will be responsible for reviewing patient documentation for encounters that has been added to an Electronic Health Record by a provider. You will ensure the accuracy and integrity of the codes that are used. Additionally, you will review each medical […]

Discussion Question: Read the article: Austin, S. (2011). Stay out of court with proper documentation. Nursing, 41(4), 24-30. – found in the Learning Materials/Readings • Of the four elements that mus

Discussion Question: Read the article: Austin, S. (2011). Stay out of court with proper documentation. Nursing, 41(4), 24-30. – found in the Learning Materials/Readings • Of the four elements that must be proven to determine negligence, do you think that any of them is harder to prove than others? (be sure to explain your reasoning […]