Clinical Documentation Essentials for the Hospital Resident

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Clinical Documentation Essentials for the Hospital Resident

Product Code: XCDEHPRES

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Clinical Documentation Essentials for the Hospital Resident

This library of 17 courses provides residents and other hospital-based physicians with a thorough grounding in the basics of compliant clinical documentation. Learners will be able to describe how complete and accurate documentation ensures an accurate depiction of a patient’s severity of illness. After completing all courses in the library, learners will have the opportunity to take a final examination and earn a certificate of documentation integrity along with CME and CCDS credits.

Each course in this library is written by physicians, for physicians, and includes case examples to reinforce its concepts. Nine clinical courses cover definitions of approximately 30 diagnoses from evidence-based literature, incorporating specific terminology usage to capture proper severity of illness. Each course is short, averaging 10–12 minutes, and is responsive to mobile devices—specifically designed to be reviewed on the go by busy residents.

Course objectives:

At the end of this session, learners will be able to:

  • Explain the importance of accurate documentation for quality and reimbursement purposes
  • Identify documentation needs for common diagnoses throughout the major body systems
  • Describe how complete and accurate documentation assists with compliance and determining the medical necessity of admissions
  • Define common diagnostic terms needed for accurate coding
  • Describe the basics of coding, hospital reimbursement, and audit and regulatory initiatives


Audience:

The target users of this course are hospital residents, although hospitalists and other hospital-based providers would also benefit. The course is applicable to specialists, but since it covers 30 total diagnoses, it is unlikely to contain enough detail for a specialist to benefit from it. Typical users’ titles include:

  • Resident
  • Fellow
  • Hospitalist
  • Physician-General
  • Internal Medicine 
  • Attending Physician
  • Physician Assistant
  • Nurse Practitioner
  • Physician Advisor to CDI


Duration: 

Each course is 10–12 minutes long, designed to be reviewed by the busy resident.
The entire program takes about four hours to complete, including the one-hour final exam.


Course List

  • Course Introduction
  • CDI and Its Importance
  • Clinical Terms vs. Coding-Based Language: Understanding the Difference Between Physician Medical Terminology and Coding-Required Terminology
  • Coding Primer
  • Hospital Reimbursement
  • ICD-10
  • Patient Status: Inpatient vs. Observation
  • Recovery Auditors
  • Common Documentation Needs for Diagnoses of the Circulatory System I
  • Common Documentation Needs for Diagnoses of the Circulatory System II
  • Common Documentation Needs for Diseases of the Endocrine System and Skin
  • Common Documentation Needs for Diagnoses of the Gastrointestinal System
  • Common Documentation Needs for Diagnoses Related to Injuries and Medication Reactions
  • Common Documentation Needs for Diagnoses of the Nervous System
  • Common Documentation Needs Related to Renal Function
  • Common Documentation Needs for Diseases of the Respiratory System
  • Common Documentation Needs Related to Systemic Infection and Shock

About the Authors:

Timothy N. Brundage, MD, CCDS, is the medical director of Brundage Medical Group, LLC, in Redington Beach, Florida. He is a diplomat of the American Board of Internal Medicine and actively practices clinical medicine as a hospitalist at St. Petersburg (Florida) General Hospital. He is an assistant professor at Lake Erie College of Medicine, where he teaches resident physicians through daily hospital rounds; reviews their documentation; and proofs their dictated history and physicals, discharge summaries, and progress notes. Brundage is a former ACDIS board member and frequently lectures to physician groups on documentation. He is also a founding board member of the American Society of Medical Advisors and its chair of education.

Brett Hoggard, MD, is the medical director of a hospitalist group in St. Petersburg, Florida, and has been practicing as a hospitalist since 2002. He is a diplomat of the American Board of Internal Medicine and a member of the Society of Hospital Medicine and the American Society of Medical Advisors. He is an assistant professor at Lake Erie College of Medicine and directs the hospital medicine rotation at Northside Hospital in St. Petersburg. He also works as a consultant with the Brundage Medical Group, specializing in clinical documentation improvement, insurance claim denials, and process improvement projects.


Continuing Education

Association of Clinical Documentation Improvement Specialists (ACDIS)
This program has been approved for 5.5 continuing education units toward fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification, offered as a service of the Association of Clinical Documentation Improvement Specialists (ACDIS).

Continuing Medical Education
This activity has been planned and implemented in accordance with the essential areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of The Greeley Company, Inc. and HCPro. The Greeley Company, Inc. is accredited by the ACCME to provide continuing medical education for physicians.

The Greeley Company, Inc. designates this educational activity for a maximum of 5.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.


Main Library

You will have access to the library for 365 days from the purchase/order date.