一个财政上合理的,基于证据的解决方案,以克服医生计费指南的复杂性:以医生为中心的笔记模板
Escher Howard-Williams1, Rachel Knight2, Paul Ossman1
1University of North Carolina School of Medicine, USA.
概括
实施标准化历史和物理 (H&P) 笔记模板显著改善了医疗保健文档和收入捕获,优于单独的教育干预措施,以获得更好的临床和财务结果.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 医疗信息学 医疗信息学
- 医疗保健管理的管理
背景情况:
- 有效的医疗保健文档和编码对于患者护理,安全,工作流程和准确的计费至关重要.
- 历史和物理 (H&P) 笔记是临床文档的基石.
研究的目的:
- 为了增强H&P笔记文档和收费捕获流程.
- 整合编码和计费方面,以准确调整收入与业绩.
主要方法:
- 一个多学科团队开发并测试了一种标准化的H&P笔记模板.
- 进行了教育工作,随后向医院医生传播模板.
主要成果:
- 标准化H&P模板的实施导致了每次遭遇平均工作相对值单位 (wRVU) 的立即增加.
- 延长时间代码和医疗决策短语的增强捕获推动了wRVU的增加.
- 与单独教育相比,模板的使用与升高的wRVUs有持续的相关性.
结论:
- 协同设计的,用户知情的H&P模板比单独的教育更有效地提高了临床实践和编码准确性.
- 标准化的文档工具提高了医疗机构的临床和财务结果.
更多相关视频
相关概念视频
01:06Legal Guidelines for Documentation
1.3K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.3K
01:23Methods of Documentation V: CBE
874
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
874
01:30Health Information Technology and Healthcare Information System
795
Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
795
01:26Guidelines for Nursing Documentation II
1.0K
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.
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.
1.0K
01:30Guidelines for Nursing Documentation I
1.0K
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.
1.0K
01:11Guidelines for Writing Outcome
2.6K
When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...
2.6K