title: Get documentation improvement in order or risk major trouble.
abstract: Clinical documentation improvement is taking on a bigger importance as payers tighten reimbursement rules, public reporting of hospital data increases, and a variety of auditors are scrutinizing hospital records, making it imperative that the medical record accurately reflects the patient's condition and the services he or she received. Assemble a multidisciplinary team to create and monitor your documentation improvement program. Develop a training program for your documentation improvement staff. Encourage collaboration between the documentation staff and case management. Look for opportunities for improvement and track your outcomes.
mesh_terms: D019090:Case Management / Q000458:organization & administration; D059019:Clinical Coding / Q000592:standards*; D003953:Diagnosis-Related Groups; D006801:Humans; D012308:Risk Management; D014481:United States