Documentation Improvement ideas

I am facilitating a project within my facility that will focus on documentation improvement for our Hospitalist program. I'm interested in hearing if other facilities have performed a similar project, what approach was taken and the outcome.

Thanks in advance.

Kristen Denney, MA, RHIA
Director, HIM - MedStar Good Samaritan Hospital
Director, HIM - MedStar Franklin Square Medical Center
PH (443) 444-3889 (GSH)
PH (443)-777-7274 (FSH)


  • edited May 2016
    Our facility does not have hospitalists, but we did implement a
    documentation improvement program four years ago. We used a vendor
    product and education. The tool provides a means for the clinical
    documentation specialists and coders to document query activity, track
    the working DRG and Final DRG. The tool provides reports on the CDS
    activity, physician compliance and the financial impact of the final
    DRG. The CMI did significantly improve. However, it seems we still
    have many retro queries to hold up coding.

    Sheila Schultz

    Director of Medical Records

    Wheeling Hospital

    One Medical Park

    Wheeling WV 26003


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