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Medical Records and Documentation Specialists

Medical Records and Documentation Specialists

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clinical documentationComplete and accurate medical records and clinical documentation is ever so helpful to the litigation team. It is also essential for the financial health of the healthcare provider.

Diagnosis-related groups (DRGs) codes are based on the accuracy of the medical record, and these codes form the basis for reimbursement. Some facilities are using nurses (clinical documentation specialists) to look over the shoulders of the staff to ensure that the medical record reflects the care being given so every possible dollar is collected.

Clinical Documentation Specialists

Don Shaw, vice president of revenue cycle at Baton Rouge General Medical Center, was quoted in HealthLeaders, November 2014, as saying, “We do have clinical documentation specialists who are all seasoned nurses up on the units working with the doctors. We have a really good partnership with our coders and our documentation specialists on communicating with each other. We are putting a lot of emphasis on this, not only for monetary reasons but to make sure we have documentation there so we can provide good care and get reimbursed for it.”

HealthLeaders is a magazine published 10 times a year that focuses on the business aspects of health care. Today’s CEO is exquisitely aware of the financial challenges of running a healthcare organization.

The clinical staff is also very aware of the challenges of recording care so that critical information is conveyed to others on the team. Clinical documentation started as a way to create a narrative, to tell the story of the patient’s care. However, it has morphed into a way to get reimbursed, to measure quality, and to provide a rationale for what happened in the event of litigation.

Medical Error Disclosure

When a medical error occurs, the medical record’s wording can be crucial, as we know in the litigation world. We also know that risk managers may be consulted before the physician prepares the note. Together they create the wording which describes the error and the disclosure conversation (telling the patient and/or family). Defense attorneys may be aware of these conversations, and plaintiff attorneys might find out about them during a deposition.

Do documentation specialists provide another opportunity to counsel providers on the careful wording of notes?

Is this dialogue possible?

Doctor: “Mrs. Smith received a four-fold overdose of a medication. I have to tell her husband what happened. How would you suggest I write the note?”

Documentation specialist: “Here’s what you can say….”

How far does the documentation specialist go in helping a provider to chart?

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.

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