Reference no: EM132174114

Documentation Improvement:

Laura just finished a documentation audit for the him department at the hospital where she works. she was not surprised to learn that 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 time of completion and content.

- Discharge summaries do no meet the 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 of lack thereof.

- The diagnoses do not provide specifity.

Now that the problems have been identified, she has to come up with the solutions and their implementation.

1. Recommended steps to improve documentation.

2. Identify who should be involved in this documentation improvement program.

3. Identify any additional information that you would like to know. Justify your response.

4. Explain the problems that these deficiencies may cause a healthcare organization.5 Indentify the follow-up required to ensure that documentation improves. Justify your response.