Beef up your documentation to prepare for the future

Hospital records and data are being scrutinized more as payers tighten reimbursement, and public reporting of hospital data increases. This means that documentation in the patient record must accurately and completely represent that patient's conditions and services received. In this issue, we'll take a look at why documentation is important, reveal problem areas where documentation may need improving, and offer suggestions for choosing and training staff. We'll look at how one hospital worked with a consultant to add clinical documentation staff and why pre-billing reviews of patients who die ensure that the mortality index is correct.