Clinical Documentation Improvement Programs

Clinical documentation improvement programs help hospitals and other medical institutions in documenting medical records completely and accurately. Clinical documentation is of utmost importance to hospitals in the wake of new federal and state regulations that weigh healthcare payment against quality outcomes. Accuracy of the data on the severity of illness and risk of mortality are some points that affect the quality outcomes of a medical institution that many insurance companies take into consideration when calculating payments to their customers.

Clinical documentation improvement programs collect patient’s data pertaining to the entire period of hospitalization including health condition at the time of admission, diagnostics, laboratory procedures and equipments used and medicines administered. The data also includes the patient’s medical history and any secondary diagnosis made. Since the data is collected in its entirety, it facilitates coding and improves the quality of health-care reports. These programs also educate and train the health-care team regarding documentation guidelines. The crux of the program is to ensure that patient care is consistent and complete and a patient’s entire medical history is available at a central location that is accessible to authorized health care professionals anywhere and at all times.

A number of Clinical documentation improvement programs have been developed by various service providers such as those developed by 3M, HP3 and Wishard. 3M has built CDIP software that helps in accurately grouping hospital cases and correctly assessing the severity of illness and risk of mortality. The software also helps the health-care team to quickly identify the health-care plan required by a patient and determines the length of hospital stay required. The CDIP developed by HP3 ensures that the hospital’s revenue cycle is accurate and correctly reflects a patient’s acuity levels. HP3 has also built software programs that train physicians and other clinical staff in documentation, summary reports, and financial results. The CDIP developed by Wishard focuses on securing medical documentation that creates consistency between the reports on the severity of a patient’s illness as provided by the hospital and as reported by the physicians.

In other words, clinical documentation improvement programs help to accurately reflect healthcare services provided by doctors, nurses, physiotherapists and dieticians from the time of diagnosis till the recovery or discharge of the patient. This makes the clinicians more responsible for their actions and also ensures that the patient is provided with an accurate diagnosis and complete treatment without overlooking any minute information from his or her medical history.

New Book Offers Tools to Achieve “Wellth” – Total Health and Wellness

Glen Alex has spent her life advocating for better health for people, and now, in her new book, Living in Total Health, she offers a balanced and sometimes surprising journey into what it means to be healthy, wealthy, and wise-or what has become popularly known in the health and wellness community as “wellth.” Glen defines this new term as “the sum total of the richness and wellbeing found in good health. Wellth means being wealthy in health-that one has met certain physical diagnostic ranges and has a meaningful or joyful life. Balance.”

That balance is evident in this book because it’s not just solely about exercise or nutrition. Instead, Glen divides the book into three sections: Physical Wellth, Emotional Wellth, and Mental Wellth. Then each section is broken up into four chapters, including “Moving Your Body” (Physical Wellth), “Being Present” (Emotional Wellth), and “Stressing Less” (Mental Wellth). Each section and chapter is filled with discussion, personal stories to illustrate Glen’s points, and exercises for the reader to become more aware of and practice the topic at hand. Glen further clarifies her goal in the introduction by saying: “The purpose of this book is to offer a different perspective on health, not to regurgitate available how-to information on diet, exercise, etc. The intention of Living in Total Health is to activate your critical reasoning and challenge your adopted approach to health if you have not achieved your goals.”

One aspect of Living in Total Health that I especially appreciated was that Glen continually reminds us that all we need is already within us. She doesn’t ask us to perform any miracles but simply to do what we were naturally born to do. Rather than tell us to do hardcore exercises at the gym, she redefines exercise as any sort of activity that requires movement like a walk, yoga, or even doing laundry or washing dishes. The challenge is to get active. Sure, some people may choose to do more-and that’s great-but for most of us, Glen’s words of wisdom are a much needed reminder of how we can start.

Glen also makes it clear that we don’t have to go along with the health crowd becomes one size does not fit all. Each of us has our own individual body, and consequently, our individual nutrition needs require much more than “a patented dietary plan.” She encourages us to find out which foods our body reacts well to and to find nutritional balance in what we can enjoy and what will not upset or inflame our bodies. Other key physical aspects she focuses on include the importance of stretching, including when and how to do it, and the benefits of massage, including massage safety tips so you can ensure you find a reliable and trustworthy massage therapist.

In the section on Emotional Wellth, Glen explains the difference between feelings and emotions and how they are signals with messages for us. Perhaps the most powerful discussions in this section had to do with separating our emotions from those of others. Glen discusses the importance of setting boundaries with people, including emotional ones. Sometimes we may have to draw the line with someone about how to treat us, but we may also have to draw an emotional boundary that we do not let ourselves cross when it comes to taking on other people’s problems. While we can be sympathetic to people, Glen warns us against metaphorically putting on someone else’s shoes that aren’t ours-in other words, don’t take on someone else’s emotional baggage.

In the midst of these boundary discussions, Glen brings up the topic of domestic violence, and I think she makes a strong point here about the difference between a conscious and a thoughtless choice. So many male batterers will claim that a woman’s behavior is what drove them to beat her, but if that’s true, why don’t those men just leave the women so they eliminate the frustration in their lives? Nor are these men incapable of containing their rage since batterers will not behave abusively in public but only at home, which is proof that people make conscious choices.

In the final section on Mental Wellth, Glen focuses on how the accumulation of unhealthy life choices commonly impact the mental health and stability of the majority of us. At the forefront of mental issues is how stress affects us, and Glen offers tips for how to reduce it. She also helps us rethink our support systems, and she introduces the concept of creating an ecomap of your support system as an effective exercise to gain greater mental wellth in your life.

Living in Total Health contains so much more than I can go into in this short review, and throughout the book’s pages, Glen tells it to us like it is, in a kind, yet straightforward manner, like the good coach she is. Toward the end of the book, she explains her mindset about her purpose in life which informed her writing of this book: “I strive to fulfill my purpose for being on this earth, to actualize and share my inner gifts with others. My truth and the perennial state of love provide the foundation I need to reach my goal to become the best version of Glen and reflection of my Creator that I am capable of being.”

We should all strive for a similar purpose, and we can achieve it. Reading and practicing the principles in Living in Total Health is a good step toward that achievement and a greater sense of happiness and wellbeing all around.