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Practice tip of the week: Improving clinical documentation


Your weekly dose of wisdom from the Physicians Practice experts.

lightbulb doodle © Matias - stock.adobe.com

lightbulb doodle © Matias - stock.adobe.com

With all the useful information available on Physicians Practice, it is easy to become overwhelmed.

With this in mind, the tip of the week is a chance to reflect on some of the wisdom found all across the site. In this February 2023 story on improving clinical documentation in your practice, Hariharasudan Neelarathinam gives these tips:

Assess communication

You must make sure that your organization's CDI staff, physicians, and coders are all in good communication with one another. If problems keep coming up, they must be fixed.

Reduce shorthand

Finding areas of miscommunication among these groups is one of the main goals of communication assessment. This misunderstanding could result from using illegible or unfamiliar shorthand.

Because shorthand only functions if all parties understand and agree upon its meaning, it may result in misunderstanding or inaccuracy. Clarifying shorthand-written words or avoiding them entirely are both important parts of resolving the problem.

Collecting patient information accurately

You must gather complete demographic and insurance data during the patient screening procedure. A solid claims process is built on the collection of reliable patient data.

It is crucial to get a duplicate of the patient's insurance card. Asking for a duplicate of the health insurance card at each visit and comparing it to the information in your system is best practice when dealing with repeat customers. The offices that don't use this procedure frequently have their claims denied because their patient demographic data is incorrect.

If your clinic notices a sudden increase in denials or a pattern of consistent denials, there may be a problem with the intake procedures. After several claim denials, giving your front desk employees feedback enables them to identify the underlying cause, make the necessary corrections, and gather the data essential for future clean claims.

Click here to read the rest of the article and be sure to check back next week for another Tip of the Week!

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