Week 4 Portfolio Outline
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Week 4 Portfolio Project
Natasha Lilly
MCCG210 – Clinical Documentation
Instructor Joseph Sambriski
05/26/2024
Week 4 Portfolio Project
Introduction
o
Brief overview of the importance of maintaining complete health records in accordance with Medicare Conditions of Participation (CoPs) requirements. I will give a brief explanation of the requirements.
Body
o
The first paragraph will provide a detailed explanation of the seven criteria for high-quality documentation. It will also explore the relationship between quality documentation, regulatory compliance, and reimbursement.
Legibility
Reliability
Precision
Completeness
Consistency
Clarity
Timeliness
Reference 1: AHIMA Work Group. “Best Practices in the Art and Science of Clinical Documentation Improvement.” Journal of AHIMA 86, no. 7 (July 2015): extended online version
o
The second paragraph will provide a description of the impact of poor documentation, covering how it can affect both the patient and the physicians.
Reference 2: Kate. (n.d.). Realizing the Benefits of Clinical Documentation Improvement . Realizing the Benefits of Clinical Documentation Improvement.pdf
o
The third paragraph will discuss the key components that contribute to the decrease in the CMI. The key components leading to the decrease in the CMI are coding accuracy, documentation
specificity, the volume of highly weighted DRG, and annual updates to relative MS-DRG weights. The case mix index is affected by the coding accuracy.
Mack, R. (2020). Auditing CDI: Pros, Cons, and Everything in Between
, 1–4.
Conclusion
o
Summary of the key points discussed in the body of the project.
References
o
List of resources used in the project.
Mack, R. (2020). Auditing CDI: Pros, Cons, and Everything in Between, 1–4.
Kate. (n.d.). Realizing the Benefits of Clinical Documentation Improvement . Realizing the Benefits of Clinical Documentation Improvement.pdf
AHIMA Work Group. “Best Practices in the Art and Science of Clinical Documentation Improvement.” Journal of AHIMA 86, no. 7 (July 2015): extended online version
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