Health Information Management

PPV: One facility starts documentation improvement process from the ground up

HIM-HIPAA Insider, July 9, 2007

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It was 1999 and long before DRGs and quality measures became healthcare buzzwords nationwide. It was a time when clinical documentation improvement programs were on few facility radars, let alone a steadily climbing trend.

But this didn't stop North Carolina Baptist Hospital, an 880-bed teaching facility located in Winston-Salem, NC, from venturing into the unknown world of documentation improvement.

Without even so much as a model facility or software guidance program to help take the first steps, North Carolina Baptist started the hard way: from the ground up. The hospital's documentation improvement program--which falls under its case management department and originally included eight clinical documentation consultants--began small and with a primary focus on revenue enhancement.

If your facility doesn't already have a documentation improvement program, consider modeling one after North Carolina Baptist Hospital's program that has exceled in capturing severity data and enhancing revenue for the past eight years.

Editor's note: For more information on how this facility grew its own documentation improvement program, click here. Subscribers to Medical Records Briefing can read the full article in the July 2007 issue. You can also purchase this article for $10.

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