Register now for CAP’s November 21 webinar, which will provide time-saving techniques for establishing and maintaining an efficient documentation system. Physicians of all specialties and practice settings will benefit from invaluable insights to help you avoid common documentation pitfalls and lower your liability risk, expedite reimbursements, and streamline patient visits. Register here: https://lnkd.in/gN6TE_kK
Cooperative of American Physicians, Inc.’s Post
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This week, Candello released their 2024 Benchmarking Report entitled "For the Record: The Effect of Documentation on Defensibility and Patient Safety." The report was written to provide physicians, APPs and nurses with practical insights and recommendations to improve their documentation practices and reduce their personal malpractice risk and enhance the safety of their patients. While the report is primarily geared toward doctors and mid-level providers, it could be beneficial for anyone who is responsible for managing documentation. Here are some key findings of the report: • 20% of cases involve at least one documentation failure. • Documentation issues more than double the odds that a case will close with an indemnity payment. • Common documentation errors that significantly increase payment odds include alterations to the medical record, insufficient documentation of clinical findings, rationale, and informed consent. Since 2011, MIEC has partnered with Candello to provide analysis and benchmarking of claims data and insight into the drivers of medical malpractice claims. Candello maintains a growing database of over 460,000 national MPL claims. The benchmarking report can be downloaded here: https://lnkd.in/gKjetmui
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Ensuring Safe Transitions: The Importance of Clear Discharge Documents for Patients As healthcare professionals, we know that a well-crafted discharge document is crucial for patient safety and optimal outcomes. Clear discharge documents: 1. Reduce medication errors and readmissions 2. Enhance patient understanding and engagement 3. Streamline communication between providers 4. Improve continuity of care during follow-up visits Best practices: 1. Use clear, concise language 2. Include essential medication information 3. Provide actionable instructions in language patients understand 4. Specify follow-up appointments and contacts 5. Accurately document diagnosis 6. Include relevant lab results, imaging, and others tests findings 7. Ensure documentation of accurate medical history and examination By prioritizing clear discharge documents, we can improve patient care, reduce errors, and enhance overall well-being – from hospital to home and beyond. Our patients deserve this level of attention and care from us.
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Last chance to register for our webinar taking place Wednesday, March 20th! Amanda Waesch will lead a discussion titled: What To Do When You Receive an Audit: Helpful Tips and Tricks. Amanda will discuss proactive tips and tricks that providers can implement when they receive a request for medical records or notice of an audit. During this webinar, attendees will learn best practices for responding to medical records requests and strategies to consider in order to mitigate additional audits and overpayments determinations. Lastly, this webinar will explore the necessary factors providers should analyze in determining whether to voluntarily refund an identified overpayment versus utilizing the OIG self-disclosure protocols. To reserve your spot please visit our website: https://lnkd.in/ez6Qdq_c #audit #medicalrecords #medicalaudit #medicalwebinar #selfdisclosure
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These upcoming changes emphasize the importance of adaptability in healthcare. As reimbursement shifts, the focus on delivering high-quality care becomes even more critical. This is a valuable opportunity for wound centers to reassess their approach and prioritize what truly drives outcomes. If you're looking to navigate these new requirements with confidence, this guide offers valuable insights. #WoundCare #HealthcareInnovation #SkinSubstitutes #CMSUpdates #QualityCare #PatientCenteredCare #HealthcareCompliance #HospitalLeadership #WoundCenters #CTP
Major changes to Skin Substitute reimbursement are here, with stricter rules and a reduction of reimbursable products. We've excelled without over-relying on these products, proving quality care is key. Our guide breaks down the new documentation, coding, and utilization requirements effective February 2025. Understand the final CMS rule for skin substitutes and CTPs and get actionable steps for wound centers and hospitals. Prepare now: 👉 https://lnkd.in/ggPXyGNw
CMS Wound Care Compliance
thewca.com
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Root Cause Analyses (RCA) are an important part of the healthcare industry's improvement and learning process. They help us understand factors contributing to adverse events and implement preventative measures to improve patient care. Read our blog on common RCA mistakes. https://bit.ly/3QHU0fn
Three Common RCA Mistakes
blog.centerforpatientsafety.org
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Top 5 Components of Effective E&M Notes: Boost Your Documentation Quality 1. Chief Complaint (CC): Clearly state the reason for the patient's visit. This should be a brief description, such as "headache," "chest pain," or "annual physical." 2. History of Present Illness (HPI): Provide a detailed account of the patient's current condition. This includes location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. 3. Review of Systems (ROS): Conduct a comprehensive review of the patient's symptoms across different bodily systems. This helps identify any other issues that might need attention. 4. Physical Examination (PE): Document the findings from your physical exam. Include observations, measurements, and any tests performed during the visit. 5. Assessment and Plan: Summarize your diagnostic impression and outline the plan of action. This should include treatment, further testing, patient education, and follow-up instructions. 📌 Pro Tip: Ensure clarity, consistency, and completeness in your notes. This not only enhances patient care but also safeguards against potential legal and billing issues. #Healthcare #MedicalDocumentation #EMNotes #PatientCare #MedicalProfessionals
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✍ New on the PAC Blog ✍ "Patient scheduling isn’t as simple as it seems. Behind every booked appointment is a complex process, requiring expertise in both medical terminology and customer service. According to the PAC 2023 Benchmark Survey, 37% of bookings are lost due to cancellations or no-shows, and the fight to fill these slots begins again. Join us as we explore strategies to overcome scheduling challenges and maximize patient access." In this Blog post, Chris Profeta, MPH explains why defining this metric is a crucial step in providing excellent patient access. To read the full blog post, click here: https://lnkd.in/eRqJGFDY
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I can "view" what you are seeing.... creepy right??? Last week, I had the privilege of working with an attorney client over Zoom to review audit trail findings for a case. This attorney had never had anyone interpret audit trails for her before, so I spent the first 5–10 minutes explaining what audit trails are, the type of information they contain, and how this data can directly impact the case strategy. As we jumped into the findings, she was stunned by the depth of information I was able to find. After an hour of discussion, she said, "Where have you been hiding?" and remarked, "I can think of so many cases where these audits would have been so helpful." For this particular case, the audit trails revealed a critical 3-hour delay in administering a lifesaving cardiac medication. The nurse acknowledged the order and looked at it five times during that 3-hour window but failed to administer the medication until much later. When prompted by the MAR (Medication Administration Record) to explain why the medication was given late, the nurse simply responded, "No comment." None of this vital information was available to us in the traditional medical records. Hearing comments like these reaffirms why I love what I do. Audit trails are a powerful tool that can provide invaluable insights into the timeline, actions, and documentation integrity within medical records—information that can make or break a case. Have you ever had that feeling that something was missing, you just knew it? That gut feeling was probably right... =========================== Hola! My name is Maria Hagen. I am an emergency room nurse with over 12 years of experience, and I am here to help you with your cases. I am not for the plaintiff nor the defense; I only stand behind the standard of care. [email protected] 708-205-6854
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