Progress / Resident Progress and Consultation Notes are now available by your “Specialty“. The breakdown of these documentation via specialty will make it easier for all Physicians’ to understand the type of note documented for each patient profile. The content for all the notes are the same for all of the specialties. This is active for all locations: Huntley, McHenry and Woodstock. When searching for a documentation, you can search by your specialty, so the result(s) can be populated unique to your specialty. Below are the new specialties added for each of the note title. Review the image below, on how the documentation list would view once signed.
Specialties included for Progress / Resident Progress and Consultation Notes are:
Centegra Health has partnered The Advisory Board Company to launch an ICD-10 Physician Documentation Education in October 2014.
Join us for a clinician-led introduction to the importance of ICD-10 and documentation improvement. This session will be focused on how simple word choice has a dramatic impact on the perceived acuity of our patients. Specifically, attendees will benefit from:
Getting credit where credit is deserved: accurate reflection of SOI, ROM, and quality scores
Strategies for improved documentation supporting SOI and ROM for today that will ease the transition to ICD-10
We provide excellent care to our patients. This effort is not about changing the way we practice medicine, or demanding that we document more; rather, it’s about getting credit for all that you do and helping us document in a way that captures all the good work we do now as well as in the ICD-10 environment.
Thank you in advance for taking the time to help Centegra achieve our quality goals.
Kumar Nathan, MD VP, Clinical Effectiveness
Irfan Hafiz, MD VP, Medical Affairs
7 to 8am
Internal Medicine (Internal Medicine, Hospitalists, Family Medicine, Gastroenterology, Hepatology)
Finding Visit ID’s for patients that are pre-registered for a procedure, study, or surgery can be done in 2 quick steps.
While inside your census (My Patients or Group & My Patients) switch the Bed Filter and the Pt. Type to ALL and click search.
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Your census list will be expanded to show “Pre-Reg” patients. Pre-Reg patients are patients that have been pre-registered for imaging studies, procedures, or surgery. The Visit ID will show up in the same place as the admit patients.
Click Picture To Enlarge
Please remember to use the Visit ID when dictating.
There are updates to the 2 midnight macros for documentation. All future macros will begin with a period (.). This will allow for consistent naming. The previous 2 midnight macro will continue to work as well.
The patient is expected to need 2 midnights of inpatient care for the management of (add diagnosis) that is complicated by (add co-morbidities), and who has a significant risk of (add complications) if not hospitalized.
The patient’s (add S & S or Diagnosis) improved after (add outline of treatment) in less than 2 midnights. Therefore, the patient is being discharged (add date) to (add destination) to follow up with Dr. (add physician) in (add # days) days.