Pearls for Clinical Documentation Improvement: A Case-Based Discussion

Needs Statement

Faculty physicians and allied health practitioners actively involved in patient care in both the inpatient and outpatient setting at BTH, HHS, BCM CHI St. Luke's, the VA, and the Baylor Clinic need to be updated on strategies for implementing new educational techniques, synthesizing and applying the evidence on current general medicine topics, and analyzing effective transitions of care and other systems based practices. The series aims to broaden the awareness of learners in these topic areas and enhance their skills to improve patient outcomes.

Educational Objectives

At the conclusion of the session, the participants should be able to:

• Distinguish the basic components of the Medical Severity - Diagnosis Related Group (MS-DRG).
• Describe the quality metrics derived from MS-DRG selection.
• Discuss the importance of optimal clinical documentation during care of the hospitalized patient.
• Demonstrate accurate and specific documentation of common clinical diagnoses in the hospitalized patients.

Target Audience

Accreditation/Credit Designation

Baylor College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Baylor College of Medicine designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Term of Approval

June 1, 2022 through June 30, 2024. Original release date: June 1, 2022.

Disclosure Policy

Baylor College of Medicine (BCM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for physicians. BCM is committed to sponsoring CE activities that are scientifically based, accurate, current, and objectively presented.

In accordance with the ACCME Standards for Commercial Support, BCM has implemented a mechanism requiring everyone in a position to control the content of an educational activity (i.e., directors, planning committee members, faculty) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships at the time of the activity or within 24 months prior.

In addition, BCM has requested activity faculty/presenters to disclose to participants any unlabeled use or investigational use of pharmaceutical/device products; to use scientific or generic names (not trade names) in referring to products; and, if necessary to use a trade name, to use the names of similar products or those within a class. Faculty/presenters have also been requested to adhere to the ACCME's validation of clinical content statements.

BCM does not view the existence of financial relationships with commercial interests as implying bias or decreasing the value of a presentation. It is up to participants to determine whether the relationships influence the activity faculty with regard to exposition or conclusions. If at any time during this activity you feel that there has been commercial/promotional bias, notify the Activity Director or Activity Coordinator. Please answer the questions about balance and objectivity in the activity evaluation candidly.

All of the relevant financial relationships listed for these individuals have been mitigated.