To Be a Great Physician, You Must Understand the Whole Story I posted this a while back and thought it prudent to post again given the successes Keith Stokes, MD, Jacob Martin, and I are having working with Open Source MD, Inc. hospitalists at their hospital client. Our approach to physician documentation improvement is to promote and advocate for complete and accurate physician documentation, making a compelling case to physicians that the medical record serves first and foremost as a communication tool versus a reimbursement tool as most CDI programs treat and see the medical record. Physicians must see the medical record as a tool to convey a patient story, a version of a short novel with an introduction, body, and ending. In this case, the story begins with the H & P, the body is the progress notes, and the discharge summary is the ending. A better approach to physician documentation education and training is to work with physicians as collaborators and facilitators of clear, concise, consistent, contextually correct, and organized physician documentation that adequately tells, describes, shows, and reflects the patient's true clinical story, need for hospital level of care, the establishment of medical necessity, shows the progress of the patient, and readiness for discharge. Physician's assessment with diagnoses accompanied by a congruent plan of care, supported by the clinical facts, clinical information, and clinical context as taught for physicians to document, will make for far better documentation that will stand the test of time, less prone to payer denials and costly financial takebacks. This process is what all CDI programs must subscribe to in the quest to refer to themselves as "clinical documentation integrity specialists." Reach out to me to learn more about how best to revamp, rebrand, and reengineer your CDI program for optimal success Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” The great physician understands the patient and the context of that patient's illness. I submit to all that a great physician can effectively understand and document the entire patient story. CDI can be instrumental in helping physicians master the telling and documenting of the patient's story. #CDIfacilitator, #CDIhelpingphysicians, #masterdocumentation, Cesar M. Limjoco, M.D., Keith Stokes, MD, #cdirebranding https://lnkd.in/ezGiNmBh.
Stewart Presser
1mo
I agree
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1moSpot on Glenn. As a veteran of a few Medicare Audits, documentation and correct coding are vital. It’s not always easy when you have patients in all of the exam rooms, but taking 1 extra minute to dot your i’s and cross your t’s can save you thousands down the road. Thanks for educating those in the trenches of healthcare.