Grading Rubric for Reimbursement Project
Categories
Cover Slide – 5 pts
? Title slide included – identifies
assignment and student name (5)
Assignment Components – 75 pts
? Includes appropriate number of slides
explaining reimbursement of healthcare
inpatient and outpatient (30)
? 10 reimbursement terms defined,
abbreviations expanded, identified if
related to inpatient or outpatient
reimbursement or both (10)
? Includes appropriate number of slides
delineating clinical documentation
improvement goals and components of
high-quality clinical documentation (25)
? Includes appropriate number of slides
demonstrating how documentation
impacts reimbursement, addresses
reimbursement related to quality (10)
Quality of Presentation and Recording – 40
pts
? Slides follow 5/5/5 rule for PowerPoint
(5)
? Video is 5+ minutes (5)
? Professional setting and attire (5)
? Does not read directly from slides –
provides additional detail (15)
? Correct spelling (5)
? information organized (uses bullets and
formatting as appropriate) (5)
APA Format – 5 pts
? Separate References Slide in APA
format
125 PTS
Instructor Comments
Documentation and Data Improvement Fundamentals
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Ruthann Russo, JD, MPH, RHIT
Introduction
The absence of complete documentation in patient medical records can have a negative effect on statistical databases,
financial planning, clinical preparedness, and gross revenue for the healthcare organization. It is for this reason that every
healthcare organization should be focused on ensuring accuracy and completeness in clinical documentation, at any cost.
Documentation improvement is not a new concept in healthcare, but rather an evolving trend.
The healthcare system in the US is constantly changing. First, from a clinical perspective, we have seen a movement away
from postponing care until patients are severely ill and in need of hospitalization to preventive medical care. Along with this
trend, we have seen fewer, but more severe inpatient admissions and an increase in outpatient admissions over the past
decade. Second, from an information management viewpoint, there has been an increasing trend toward computerization of
medical records. The government has responded to this trend by implementing privacy and security protections through
HIPAA legislation. Third, reimbursement to healthcare providers for services has evolved. Many of the initial changes were
triggered by HIPAA legislation as well. These began with the Medicare fraud and abuse initiatives of the 1990s and have
continued through the present with CMS policy updates focusing on physician documentation.
The two most important aspects of patient medical record documentation are as follows:
The attending physician’s documentation is key throughout the patient’s stay. In each case, the model stresses that in
good documentation practices it is important for the attending physician to either interpret the documentation of other
clinicians or tests, or confirm the findings of other physicians.
Documentation is the key to appropriate billing. In each case, documentation forms the basis for coding and the
eventual bill that is submitted for a patient’s care.
What Is Clinical Documentation in a Patient’s Record?
Clinical documentation in a patient’s record includes any and all documentation that relates to the care of the patient during
the patient’s stay or encounter. In the inpatient setting, some of the important pieces of inpatient documentation include:
Attending Physician Documentation
In the acute care inpatient setting, the attending physician is the central point for all documentation in the patient’s record. It is
the responsibility of the attending physician to determine the relevance and importance of all other documentation in the
patient’s record. Some of the more important clinical documentation components from the attending physician during the
patient’s stay are described below.
History and Physical
The patient’s history and physical is one of the first pieces of documentation that appears on the patient’s record. This
document usually includes not only information pertaining to the patient’s history, but more importantly, pertinent information
regarding the patient’s current condition. Here, the attending physician should document his/her assessment of the patient’s
current condition. It is possible that the attending may be working with symptoms and differential diagnoses at the time of the
history and physical exam. It is important that s/he document these symptoms and any differential diagnoses in the history and
physical. Although these conditions may be eliminated once a definitive diagnosis has been established, it is important to
understand (and have documented) what the physician was working with in terms of initial or “working” diagnoses. This
information can be used to substantiate any tests or consultations that are ordered during the stay.
Example: If a patient is admitted with syncope, and the physician orders both a neurological as well as a cardiology
consultation, it is important to know that the attending physician is working with differential diagnoses of “possible CVA”
and “arhythmia.” These diagnoses (one a neurological diagnosis and one a cardiology diagnosis) justify the ordering of a
consultation from each clinical area.
Progress Notes