Clinical Documentation in Hospitals

In the wake of new laws on quality assurance in health care and the new reimbursement system for in-patient cases by means of Diagnosis-Related-Groups (DRG), clinical documentation has achieved a considerably higher significance within health care. It is no longer sufficient to capture the diagnoses and performance on the wards, in the operating theatres and the functional areas only.




Coding of Diagnoses and Therapies
Diagnosis and treatment (surgical procedures) of every patient have to be coded using the ICD 10 code, respectively the OPS classifications. The documentation of medical cases has to be processed in such a way that a coherence between diagnosis and therapy, as well as between the state-of-the-art in medicine and patient care can be reconstructed.

Organisation of Clinical Documentation Workflow
Within this workflow, we take an influence on the processing of data by designing on-screen- and paper-forms. Through diligent management of patient records during in-patient care, we provide the organisational support of the care process. By making use of our special skills, we support the transition from paper-based records to electronic patient records, as well as running archives for paper-based patient records.

Processing of Patient Information
In central administrative units, either in clinical departments or directly on the wards, we extract all relevant information from the patient records. We code diagnoses and procedures based on official classifications (ICD10, OPS). On the basis of the primary documentation, we verify already coded data, revise it if necessary and confer with the treating physicians. Finally, we group the collected DRG-data for revenue calculation by using specially designed software. Together with the physicians, we also discuss revision cases handed in by the Medical Control Service of the German health insurance companies (MDK, Medizinischer Dienst der Krankenkassen).

Training of Other Occupational Groups
Given the high relevance of medical documentation and continuously changing legal requirements, we develop internal coding guidelines and figure as contact persons regarding all questions on correct documentation and classification. We provide training material and perform training programs for physicians, nurse staff and senior house officers/ residents.

Verantwortlich für den Inhalt:
Navigationspfeil Markus Stein