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ForwardEM2602J "Words Matter: How Accurate Documentation Aligns Clinical Care with Measured Outcomes" (IM GR-02.27.26)
Purpose and Overview
This presentation will demonstrate the multiple downstream impacts of accurate inpatient clinical documentation. These include supporting medical necessity of admissions, accurately representing patients' expected mortality, and ensuring that institutional quality and safety metrics truly reflect the complexity and quality of care provided. It will also highlight preferred documentation practices and the various roles that physicians play in improving the quality of clinical documentation at UT Southwestern.
Target Audience
UT Southwestern faculty, fellows, residents and medical students, community physicians, nurse clinicians, physician assistants and nurses.
Learning Objectives
At the conclusion of this activity, the participant should be able to:
- Understand the evolution of clinical documentation and its role in clinical communication.
- Identify the downstream impact of accurate documentation on expected mortality rates as well as institutional quality metrics and safety scores.
- Recognize how clinicians, clinical documentation integrity specialists, and coding specialists impact the quality of documentation at UT Southwestern.
Vatsala Goyal, M.D.
Clinical Associate Professor of Internal Medicine
Division of Hospital Medicine
Lead Physician Advisor for Clinical Documentation Integrity
UT Southwestern Medical Center
Available Credit
- 1.00 AMA
Price
Required Hardware/software
Activities should be run with recent versions of common browsers, including Internet Explorer, Firefox and Google Chrome