Reference no: EM133946393

Problem

Tiffany just finished a documentation audit for the HIM department at the hospital where she works. She was not surprised to learn there were significant documentation problems. The top four problems identified were the following: History and Physicals (H&Ps) do not meet medical staff bylaws for the completion and content. Discharge summaries do not meet Joint Commission, Centers for Medicare and Medicaid guidelines for documentation, and medical staff regulations for completion and content. Progress notes are very brief and do not adequately describe the patient's improvement or lack thereof. The diagnoses do not provide specificity. Now that the problems have been identified, you are here to help her come up with solutions and how to implement them. Recommend steps to improve documentation. Identify who should be involved in the documentation improvement plan. Get the instant assignment help. Identify any additional information that you would like to know. Justify your response. Explain the problems these deficiencies may cause your healthcare organization.