Does Improving Medical Record Documentation Better Reflect Severity of Illness in Neurosurgical Patients?

Impact of Electronic Health Record Documentation and Clinical Documentation Specialists on Case Mix Index: A Retrospective Study for Quality Improvement

“…However, recent research has shown that provider documentation compliance is difficult to achieve, despite quality methodologies and study designs using traditional paper populated charts [7]. Moreover, with the adoption of mandated EHRs, failure of providers to perform accurate and comprehensive documentation has the potential for negative quality and financial impacts for promote physician involvement and to achieve buy-in for the EHR and clinical documentation system.…”

An Audit of Documented Rehabilitees` Data at the Workers` Compensation Rehabilitation Centre (WCRC) in Bulawayo, Zimbabwe

“…It facilitates communicat ion and continuity of care among health care professionals involved in the patient care. Medical records serve as medico legal documents should med ical malpractice be alleged and they should be able to withstand scrutiny in court [7]. They facilitate accurate and timely claims rev iews and pay ment.…”

“…The presumption is that after controlling the patients" severity of illness, residual differences in mortality rates relate to differences in quality of care. Corporations such as Thompson Reuters have created a market ing tool and "status" based on this informat ion that hospitals may strive to achieve [7]. Anonymous individual med ical records may serve as a docu ment to educate med ical students/resident physicians and to provide data for med ical research.…”