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If your documentation assurance program focuses on reimbursement alone, you're not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it's critical that the medical record accurately reflect the severity of illness and the services provided to your patients.
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Regular audits and continuing education are the keys to a successful documentation assurance program, says Liz Youngblood, RN, MBA, vice president, patient care support services at Baylor Health Care System in Dallas.
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"When I conduct an initial review of the chart, I read it from the beginning, like a story starting with the emergency department notes, through the history and physical and start building a story from a clinical standpoint.
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An emergency physician is managing an acute myocardial infarction, arranging for a patient transfer, sewing up a laceration, and putting in a chest tube, with 20 people still waiting to be seen in the waiting room.
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When the Marshfield (WI) Clinic launched an ambitious biobanking project, organizers knew they'd need significant community buy-in.
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President Barack Obama's long-stated goal for universal health insurance could have a ripple effect on the human subjects research field, possibly removing an incentive for people to enter clinical trails. That is one of several possible changes on the horizon as a new administration takes the helm, experts tell IRB Advisor.
