the importance of proper documentation and ways to ensure documentation is complete and accurate DQ
As part of your internship with South Padre Medical Center, you are working under the supervision of the coding supervisor, Marla Kauffman. The clinic’s CDI Director, George Bowman, wants to better educate the physicians on the importance of accurate and complete medical records. Therefore, George is planning on beginning a series of education sessions every month. He has asked Marla to prepare a presentation on proper documentation.
Marla thinks that helping with this presentation would be a wonderful opportunity for you during your internship so that you can learn how to improve clinical documentation by identifying some key elements that are missing or unclear inpatient documentation. Marla’s plan for the presentation is to present some cases and examples where the coders did not have the information they needed to code. Marla has asked you to assist in preparing for this presentation by identifying any missing or unclear information from four patient records and drafting a PowerPoint presentation on your findings.
Because you are a new coder, Marla also thinks it would be helpful for you to research the importance of proper documentation and ways to ensure documentation is complete and accurate and then include information from your research findings into your PowerPoint presentation.
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You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument