âGet up, Stand up, Stand up for your Rightsâ

Stevens, Camilla

doi:10.1057/9781137027108.0017

Cited by 1 publication

(1 citation statement)

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“…With the institution of the new Medicare codes, increased chart documentation is necessary to maximize reimbursement [4]. Figure 5 illustrates the new Current Procedural Terminology (CPT) codes for an Outpatient visit.…”

Section: Chart Documentationmentioning

confidence: 99%

Computer Database for Melanoma: A Clinical Management and Research Tool to Ensure Continuous Quality Assessment

Reintgen

Cw²,

K³

et al. 1993

Seminars in Surgical Oncology

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The need for an efficient method to handle data and for chart documentation is more apparent today than at any time in the past. High volume clinics for screening, diagnosis, and treatment are the rule rather than the exception in modern practice. A papermill medical record department or tumor registry fails on a day‐to‐day basis because of inefficiency of data collection, filing, storage, and abstraction. Requirements of the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) include the setting of standards and the ability to query data to ensure the standards are met. A PC‐based software program has been developed with the following features: (1) ongoing timed queries of the data are possible on any variable collected in the database to monitor trends in the standards established for care in the clinic; (2) a daily update of the database is performed so that it may be used as a clinical management tool, acting as an electronic medical record or as a clinical research tool; (3) the software will summarize the chart by abstracting a predetermined list of key data elements to improve clinical efficiency; (4) chart documentation is improved for Medicare coding requirements to maximize physician reimbursement; and (5) clinic notes and referral letters are generated the same day as the clinic visit to allow patients to have a copy of their clinic notes or for same day FAXing to the referring doctors. To date, > 1,200 patients with melanoma have been registered and entered into the system. The system acts as a melanoma database for the State of Florida by registering 10% of the new cases diagnosed in the state. The use of the database allows the natural history of various subgroups of the melanoma population to be defined in a state in which the disease is “epidemic.” In this way, populations can be identified who have a good prognosis and can just be followed or other subgroups identified who are candidates for adjuvant protocols.

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Section: Chart Documentationmentioning

confidence: 99%