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01:15Methods of Documentation VI: Case Management Model
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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...
For example, a patient with a chronic...
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01:29Documentation in Long-Term and Home Healthcare Setting
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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
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01:06Legal Guidelines for Documentation
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The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
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01:30Guidelines for Nursing Documentation I
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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
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01:26Guidelines for Nursing Documentation II
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Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
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01:20Introduction to Documentation and Reporting
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Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
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Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
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Case Management and the Documentation of Avoidable Days.
Leah N Shelerud1, Jana L Esden
1Leah N. Shelerud, MSN, RN, CCM, CRRN, is an Outcomes Manager at University Hospital in Madison, WI. She graduated with her BSN from Carroll College in 2005 and with her MSN from Edgewood College in 2016. She has been a case manager for 5 years, and her interests include accurate avoidable day documentation and complex medical care. Jana L. Esden, DNP, APNP, FNP-BC, is a Family Nurse Practitioner and an Assistant Professor at Frontier Nursing University, Hyden, KY. Her current research interests include chronic care, underserved populations, and adverse childhood experiences. In her clinical role, she works with a community clinic to serve patients at a transitional housing complex in Northeast Wisconsin.
Professional Case Management
|February 1, 2017
Summary
A system upgrade improved case manager documentation of avoidable days (ADs). Further education on ADs, their financial impact, and documentation importance is recommended for case managers and hospital staff.
Area of Science:
- Healthcare Management
- Clinical Documentation Improvement
- Health Informatics
Background:
- Avoidable Days (ADs) significantly impact healthcare organization finances.
- Accurate documentation is crucial for reducing ADs and managing costs.
- Healthcare reimbursement changes necessitate efficient financial management.
Purpose of the Study:
- To evaluate if a system upgrade with a revised documentation layout enhanced case manager compliance with AD tracking.
- To explore staff perceptions of AD documentation and its potential effect on accuracy.
Main Methods:
- A quantitative survey of case managers at a large academic medical center.
- Analysis of electronic health record data on documented ADs before and after the system upgrade.
Main Results:
- The system upgrade led to improved case manager documentation of ADs.
- Survey data indicated a need for enhanced education regarding ADs, financial implications, and documentation importance.
Conclusions:
- Case managers expressed a need for more comprehensive education on AD documentation.
- Recommendations include integrating AD education into orientation and annual reviews, and expanding it to all hospital staff for organizational commitment.