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Clinical Documentation Essentials for the Hospital Resident e-learning

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Clinical Documentation Essentials for the Hospital Resident

This library of 17 courses provides residents and other hospital-based physicians with a thorough grounding in the basics of compliant clinical documentation. Learners will be able to describe how complete and accurate documentation ensures an accurate depiction of a patient’s severity of illness. After completing all courses in the library, learners will have the opportunity to take a final examination and earn a certificate of documentation integrity along with CME and CCDS credits.
 

Each course in this library is written by physicians, for physicians, and includes case examples to reinforce its concepts. Nine clinical courses cover definitions of approximately 30 diagnoses from evidence-based literature, incorporating specific terminology usage to capture proper severity of illness. Each course is short, averaging 10–12 minutes, and is responsive to mobile devices—specifically designed to be reviewed on the go by busy residents.

Course objectives:

At the end of this session, learners will be able to:

• Explain the importance of accurate documentation for quality and reimbursement purposes
• Identify documentation needs for common diagnoses throughout the major body systems
• Describe how complete and accurate documentation assists with compliance and determining the medical necessity of admissions
• Define common diagnostic terms needed for accurate coding
• Describe the basics of coding, hospital reimbursement, and audit and regulatory initiatives

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