The Role of Hospital Medicine in Inpatient Clinical Documentation

Publication date: October 2014 Source:Hospital Medicine Clinics, Volume 3, Issue 4 Author(s): Kenji Asakura , Letizia Alto , Erik Ordal , Winthrop F. WhitcombTeaser Inpatient clinical documentation comprises physician documentation of the diagnoses that arise during an inpatient stay, and is often incomplete because of either missing information or the use of inaccurate terminology. Inadequate documentation results in an inaccurate reflection of the illness severity of patients, leading to underbilling and unrealistic skewing of research data. Clinical documentation improvement specialists can help physicians correct inaccurate documentation by identifying errors and changing their notes after the fact. Improved technology, the use of scribes, and physician education projects to ensure correct documentation at source are shaping the future of clinical documentation improvement.

Source: Hospital Medicine Clinics - October 12, 2014 Category: Internal Medicine Source Type: research