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medical documentation still a1486 .pdf


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medical documentation still a
Any Hospital that is currently looking to compete in today's market is struggling. In the last several
years, a paradigm shift has occurred in the medical industry. Thanks, in large part, to Medicare
and Medicaid requirements, many insurance companies have joined in with changing how
medical institutions receive their compensation.more...
From small, private or rural ambulance companies, all the way up to the largest medical systems,
including national leaders in medicine, everyone is now being measured by patient satisfaction.
And while this shift has created a so-called "run for the money," situation, causing many hospitals
to completely over haul their training and focus, we still can't lose focus on the basics. Simple
medical documentation can still vastly affect medical reimbursement.
Let's consider some examples, and see how medical documentation will make, or break, your
institution's bottom line.
First, consider the example of a patient who develops a medical problem regarding something
besides their primary reason for the stay. For example, if a patient comes into the hospital with a
life-threatening condition such as stroke or heart problems, this becomes a very costly visit.
If, in the course of that visit, the patient receives a urinary catheter, and later develops a urinary
tract infection, this will greatly affect the hospital's reimbursement for that visit. However, if the
admitting doctor completes documentation that accurately shows the patient had signs or
symptoms of that infection upon their arrival, before any medical treatment had begun, the
hospital is able to procure their entire reimbursement.
Even going back to the basics. We've all heard the expression when it comes to medical
documentation, "If it wasn't documented, then it didn't happen."
If a difficult or unwieldy medical documentation system is preventing your staff, be they nursing
assistants or specialized physicians, it can radically affect your institution's reimbursement.
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