2Final - Documentation Matters1

2Final - Documentation Matters1
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  2010 UBO/UBU Conference 1 Title: Documentation Matters: Why is Clinical Documentation Important? Session: Wednesday, 16 March 11, 0800-0850  Objectives  Explain the importance of clinical documentation  Describe how clinical documentation became critical with the implementation of the Medicare Prospective Payment System and other cost-reduction initiatives  Provide principles of documentation  Describe the contents of the medical record  Identify Documentation Improvement best practices  Discuss how documentation impacts quality of care, financial planning, healthcare outcomes and appropriate reimbursement  Provide documentation examples 2  Documentation Matters “If it was not documented, it was not done”    Documentation Matters Why is clinical documentation important? ã Documentation is critical for patient care ã Serves as a legal document ã Quality Reviews ã Validates the patient care provided ã Good documented medical records reduce the re-work of claims processing ã Compliance with CMS, Tricare and other payers regulations and guidelines ã Impacts coding, billing and reimbursement
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