Improving physician documentation through a clinical documentation management program

Nurs Adm Q. Oct-Dec 2003;27(4):285-9. doi: 10.1097/00006216-200310000-00005.

Abstract

Improving physician documentation ensures that the patient's clinical course is clearly recorded. North Carolina Baptist Hospital implemented interventions addressing physician documentation to ensure the assignment of the most appropriate diagnosis-related group (DRG) when it launched the Clinical Documentation Management Program (CDMP). Collaboration between registered nurses trained as clinical documentation consultants (CDC) and certified coding specialists as well as ongoing physician education has resulted in more accurate and complete documentation in the medical record.

MeSH terms

  • Concurrent Review / organization & administration*
  • Diagnosis-Related Groups / standards*
  • Documentation / standards*
  • Forms and Records Control
  • Hospitals, Religious
  • Humans
  • Medical Records / standards*
  • Medical Staff, Hospital / education
  • Medical Staff, Hospital / standards
  • North Carolina
  • Nurse Clinicians / organization & administration
  • Total Quality Management / organization & administration*