Description
Clinical Documentation for Healthcare Providers – Clinical Documentation for Neurosurgeons
Release Date: January 20, 2020
Expiration Date: January 19, 2023
Faculty:
Erica E. Remer, MD, CCDS
President and Founder
Erica Remer, MD, Inc.
Dr. Remer reports no financial relationship with a commercial interest relevant to this activity.
Target Audience
This continuing medical education activity is intended for physicians, physician assistants, nurse practitioners, residents, and medical students. It will benefit any healthcare provider who documents in the medicolegal record and wants to optimize their communication, quality metrics, and reimbursement.
Media
Recorded slides and audio presentation. Posttest will reinforce information presented.
Learning Objectives
After participating in this activity participants will be able to:
- Understand why we document
- Recognize the relationship between documentation, quality metrics, and reimbursement
- Improve their quality metrics and decrease inappropriate patient safety indicator assignment
- Incorporate more and best risk-adjusting diagnoses in their documentation
- Respond to queries in a thoughtful, appropriate, and timely fashion
Accreditation Statement
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Case Western Reserve University School of Medicine and Erica Remer, MD, Inc. Case Western Reserve University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Case Western Reserve University School of Medicine designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Planning Committee
Joan Zoltanski, MD, MBA, Activity Director
Chief Experience Officer
University Hospitals of Cleveland
Assistant Professor, Pediatrics
Case Western Reserve University School of Medicine
Dr. Zoltanski reports no financial relationship with a commercial interest relevant to this activity.
Erica E. Remer, MD, CCDS Co-Activity Director
President and Founder
Erica Remer, MD, Inc.
Dr. Remer reports no financial relationship with a commercial interest relevant to this activity.
Disclosure Statement
The policy of Case Western Reserve University School of Medicine CME Program (CWRU CME) requires that the Activity Director, planning committee members and all activity faculty (that is, anyone in a position to control the content of the educational activity) disclose to the activity participants all relevant financial relationships with commercial interests. Where disclosures have been made, conflicts of interest, real or apparent, must be resolved. Disclosure will be made to activity participants prior to the commencement of the activity. CWRU CME also requires that faculty make clinical recommendations based on the best available scientific evidence and that faculty identify any discussion of “off-label” or investigational use of pharmaceutical products or medical devices.
Instructions
To receive a statement of credit for up to 0.75 AMA PRA Category 1 CreditTM you must:
- Review and reflect on the full content of the recorded session.
- Successfully complete the posttest.
- Complete the evaluation.
- Claim your credit.
Your credits will be recorded by the CWRU CME Program and made a part of your cumulative transcript.
Estimated Time to Complete this Educational Activity
Including review of any resource material and completion of the post-test, this activity is expected to take 1 hour to complete.
Fee
The cost of this program is $189.
To contact the CME Provider: Email CWRU CME at [email protected]
Resources
CMS Evaluation and Management Services, 2016.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
Guidelines for Teaching Physicians, Interns, and Residents, MLN booklet, CMS, 2017.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf
Patient Safety Indicators, Agency for Healthcare Research and Quality
https://www.qualityindicators.ahrq.gov/modules/psi_overview.aspx
LaCharite T, CDI for Surgeons: What You and They Need to Know, presentation from ACDIS Annual Conference, May 2018.
https://acdis.org/system/files/resources/ACDIS_day1-3_track1-1_pres_0518-La%20Charit%C3%A9_f1.pdf
Zupko K, Op Note Documentation Tips Every Surgeon Can Use, KZA Blog, May 1, 2019.
https://www.karenzupko.com/op-note-documentation-tips-every-surgeon-can-use/
Gadani R, Documentation in Surgery, SlideShare presentation, July 2015.
https://www.slideshare.net/ravi_gadani/documentation-in-surgery
Mohammad LM, Kimmell K, et. al., Enhanced Documentation and Accurate Coding with the Introduction of a Standardized Neurosurgery History and Physical Template, 2019 AANS Annual Scientific Meeting, San Diego CA, April 2019.
https://thejns.org/view/journals/j-neurosurg/131/1/article-p2.xml
Spurgeon A, Hiser B, et. al., Does Improving Medical Record Documentation Better Reflect Severity of Illness in Neurosurgical Patients?, Clinical Neurosurgery, Volume 58, 2011.
Rosenbaum BP, Lorenz RR, et. al., Improving and Measuring Inpatient Documentaiton of Medical Care with the MS-DRG System: Education, Monitoring, and Normalized Case Mix Index, Perspect Health Inf Manag, 2014 Summer: 11(Summer); 1c, 2014.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142511/
