As a future healthcare professional, your role includes making clinical documentation clear, accurate, and compliant with regulations. In this assignment, you will assume the role of a clinical documentation improvement specialist.
This two-page case study measures your mastery of ULOs 2.3, 3.2, and 5.1.
As a future healthcare professional, your role includes making clinical documentation clear, accurate, and compliant with regulations. In this assignment, you will assume the role of a clinical documentation improvement specialist.
Your task for this case study is to review a patient’s chart and critique the patient notes. You will identify any issues in the documentation, including potential lack of clarity, missing details, and/or noncompliance.
Below are more detailed instructions for this case study assignment:
- Download the patient chart for Walter Moran.
- Examine the sections of the patient chart for any clinical documentation issues or areas where clarity is needed. Upload a two-page document of this case study:
- One page documenting the issues in each chart section. If there are no issues in a section, be sure to explain why it is clear and without error.
- One page on the importance of documentation accuracy in patient care. Include a real-life example of how inaccurate information can negatively impact care delivery.
- Download and complete a new patient chart for Walter Moran that corrects the issues found in the original document. Feel free to use hypothetical findings when missing specific details.
This completed case study will consent of two submissions:
- One-page document outlining the errors in the patient chart.
- New patient chart with the documentation corrections included.
Use course resources such as your textbook, unit articles, and study guides for guidance. Using outside references on the components of a detailed patient chart is suggested. If outside sources are used, please adhere to APA Style when creating citations and references for this assignment.
