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audit); evaluate occurrences of deficiencies and/or inconsistencies in medical record documentation through the healthcare provider query process, 4.
Department of Health and Human Services * Improving Health Together Challenge, sponsored by Keas * The Living Record: Rethinking Medical Record Documentation, sponsored by Szollosi Healthcare Innovation Program * Why-Health ?
The importance of coding accuracy: a review of the literature When writing about hospital morbidity data on antibiotic resistance in Australia, Hargreaves and Kok (2003: S55), observed: 'The national introduction of the Australian versions of ICD-9-CM in 1995, and of casemix-based funding and management from the mid-1990s, has possibly led to more accurate medical record documentation and improved coding of these infections and are likely explanations for the observed increase in reporting'.
Risk-Management Steps Complete and proper medical record documentation is important because it permanently reflects that the nursing care being provided meets professional standards by noting the progression of services, care, and monitoring provided to residents.
Diaz' summary suspension was based upon (1) a review of her charts, which showed at least five incidents demonstrating a substandard level of care; (2) her unavailability for over four hours while on emergency call; (3) her failure to see newly admitted patients in a timely manner, and (4) her noncompliance with the medical staff bylaws regarding timeliness of medical record documentation.
``The emergency room staff and physicians have been educated regarding the need for medical record documentation of medical screening examination of the patient to determine the condition/stability of the patient,'' records show.
To help rectify this, Medical Insurance Exchange of California (MIEC) has published a handbook, Medical Record Documentation for Patient Safety and Physician Defensibility.
The second component uses optical disk imaging technology to meet the remaining 20 percent of our EMR information needs such as advance directive/guardianship papers, medical record documentation from non-VA facilities and informed consents.