Concurrent Clinical Documentation Management
 ACCURATE BILLING  ACCURATE REIMBURSEMENT
Medical records tell a story… and when the story is incomplete, people ask questions. Coding is the numerical
language of the story; accurate coding can support your hospital through the process of regulatory audits, especially
in targeted areas such as one day stays. But accurate coding is not just the work of the HIM department.
Physician and nurse care providers must understand coding principles and work together to validate acuity and provide
accurate documentation on medical charts so that the hospital can be appropriately reimbursed. And so that your publicly
reported patient acuity matches resource use - important to payer and consumer decision making. QHR can help you
determine where documentation and coding problems occur, then work with your staff to effectively communicate with
physicians to create accurate charts every time.
QHR consultants:
■ Conduct a coding audit to assess improvement opportunities, staffing and training needs
■ Compare hospital DRG volume to national benchmarks
■ Customize on-site education for case managers/coders/physician advisors to improve clinical
documentation based on hospital-specific records
■ Provide one-on-one and group training by physician peers with your medical staff, to help them
understand the role they play in accurate documentation and hospital reimbursement and work on
problem areas
■ Continue to measure outcomes of improved process, spot checking records on a regular basis
Working with hundreds of hospitals across the U.S., QHR consultants have developed an operational focus and implemented
improvement programs in all sizes of hospitals. They have provided extensive mentoring for physician advisors, case managers
and coders, helping them develop skills to talk to physicians with confidence, grounding their questions in sound
documentation/coding principles.
Compliant clinical documentation increases your bottom line and lowers your risk. QHR identifies your specific
needs, then trains your staff to keep these improvements in place long after the consultants leave.
For more information on QHR Case Management Services, contact:
Pat Cooper, Practice Leader, 800-233-1470 ext. 4775.
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