Physician Documentation Services
EHR's Physician Documentation Service advances clinical documentation through direct physician engagement while complementing your existing CDI programs. The interactive Physician Advisor approach enables your treating physicians to receive timely, case-by-case, targeted documentation feedback on the most complex cases and associated queries while the patient is still in the hospital.
The EHR model reinforces precise and detailed documentation methods that are difficult to achieve retrospectively, or without the medical expertise and perspective of another physician. Our goal through physician-to-physician interactions is for your treating physicians to adopt these documentation requirements as best practice and consistently record patient severity and care to support accurate DRG assignment impacting CMI.
Steps our Physician Advisors take with each case:
Review Determine if greater specificity is needed in documentation.
Substantiate Clarify if a query is valid or needed.
Engage Interact directly with the treating physician to gain clarification in the documentation and provide case-specific education and feedback.
Document Provide a written summary of the physician conversation to the CDI specialist to validate the physician has updated the chart.
Download the educational white paper “Insights and Best Practices for New Clinical Documentation Improvement Programs” for practical information about CDI, what it is, and how to get the most out of it.
Learn more about the factors you should consider when starting commercial CDI case reviews with our white paper, "Achieving Accurate Commercial Reimbursement with CDI".
Download the 2015 Clinical Documentation Improvement Trends Survey Executive Summary and infographic from The American Hospital Association in conjunction with Executive Health Resources.
Contact EHR to learn more about its Physician Documentation Service.