BC Advantage - 2015 Issue 7

Documenting the Patient Record

Does your documentation tell the whole story? For documentation purposes and continuity of care, it has always been important for providers and clinicians to document the entire story. However, for reimbursement purposes, the push was not there to report what seemed to be minute details of the patient encounter.In order to begin to appreciate the implementation of ICD-10, consider that the new codes bring opportunity for much greater accuracy in creating standardized data that describes the patient's condition. Accurate, detailed and consistent data will greatly improve clinical decision making, performance reporting, managed care contracting, financial analysis, and all...

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