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The CliniNotes™ System
Improving documentation to reflect the quality and accuracy of
patient care.
The CliniNotes™ System uses physician-to-physician (peer-to-peer)
coaching to improve clinical documentation and compliance. The CliniNotes™ System affords hospital clients the ability to help their
physicians improve documentation of care and accuracy of payment.
The CliniNotes™ System achieves these goals using unique coaching systems and techniques, consistent communication materials, and educational programs. BCE Technology measures the impact of the CliniNotes™ System for both clinical compliance and financial outcomes.
The CliniNotes™ System empowers local physicians to coach their
peers toimprove the accuracy and completeness of the medical record.
As rules and regulations are constantly changing, treating physicians
gain a valuable local resource on the medical staff to help meet the
changing administrativerequirements for documentation of
patient treatment.
BCE Technology accomplishes its mission by using highly qualified
local physicians who receive training in the CliniNotes™ System, BCE Technology's proven process of physician education. This peer-to-peer coaching in clinical documentation and compliance for physicians is significantly more effective than other methods. The result is more
appropriate and timely payment, and more accurate public reporting
of physician and hospital performance.
BCE Technology's proprietary Clinical Accounting system provides
the dashboard to measure the impact of the CliniNotes™ System.
Additional education and program development can be achieved
through other unique features of the CliniNotes™ System.
1. Benefits
The CliniNotes™ System has specific and measurable benefits for physicians and hospitals:
• Compliance - The CliniNotes™ System educates physicians
regarding changes to the DRG system and current documentation
and compliance issues.
• Quality - Through documentation surveillance, BCE Technology has
identified quality improvement initiatives that benefit both the medical
staff and the hospital. In addition, JCAHO medical record scores
increase significantly with improved documentation.
• Medical Staff Relations - The CliniNotes™ System is a concurrent
process that empowers physicians through documentation reminders
(©Clinical Notes). BCE Technology's team approach connects the
medical, HIM, utilization and case management staffs.
• Liability Exposure - Accurate documentation reduces liability
exposure for both hospitals and physicians.
• Public Reporting - Documenting patient severity of illness impacts
both hospital and physician outcomes profiles that are available to
the public.
• Financial - The CliniNotes™ System has a measurable impact on
the accuracy of diagnoses and DRG assignments. This results in
significant improvement in reimbursement from payers.
• Practice Management - A series of Munch 'n LearnsT affords
practicing physicians and their staff the opportunity to gain knowledge
of initiatives, management procedures and regulatory updates to help
them in their everyday practice of medicine.
2. ©Clinical Notes
©Clinical Notes is a set of printed educational notes each of which
represents the most common diagnoses and compliance coaching opportunities seen on concurrent review. They are customized for each
client and each note contains a brief didactic portion with room for the
coach to write a personal note to the attending physician. When
appropriate, they are placed on the record at the time the coach
makes concurrent chart rounds.
BCE has found that approximately one half of the notes placed on the
record result in a more accurately assigned DRG, and the remainder
result in improved documentation compliance, creating an educational opportunity for physicians.
3. ©Clinical Accounting
BCE Technology's ©Clinical Accounting System tracks results of the
coaching efforts and provides detailed reports to its clients.
The coaching activities are summarized and presented at the time a
BCE Medical Director makes quarterly on-site client visits. These reports
not only provide ongoing financial and compliance results to the hospital administration, but also provide detail to the hospital coaches
demonstrating the results of their efforts.
For example, one of the detailed reports is also sorted by the attending physician, so that the medical leadership is aware of which attending physicians are participating in the program to improve documentation
and compliance.
BCE Technology's ©Clinical Accounting System also has a DRG
analysis component that compares DRG assignments over two or more years. The reports support the efforts of the hospital coaches, as well as providing a critical guide for service line management. This facilitates
tracking of discharges by service line, sentinel pairs and documentation
of co-morbid conditions.
4. Newsletter
Doc-U-Tips™ is a one-sided, one page monthly newsletter which
provides timely documentation information to physicians. It is published
on the first of every month and sent to every attending on staff and to administrators and directors of hospital departments. The newsletter
is also posted at every physician dictating area in the hospital.
5. Documentation Bulletin
The BCE Documentation Bulletin is a one-sided, one page monthly publication which provides timely documentation information about
one documentation issue that is common to all clients. It is published
on the 15th of every month and sent to every attending on staff and to administrators and directors of hospital departments. The bulletin is
also posted at every physician dictating area in the hospital next to the newsletter (Doc-U-Tips™).
6. Munch 'n Learn™
The Munch 'n Learn™ series are educational opportunities provided to
clients at the time of BCE's visits. At each quarterly visit, there is the opportunity to present at least 4 of these subjects to interested physicians
and hospital departments. Each Munch 'n Learn™ lasts for 45-60 minutes and is usually presented at breakfast, lunch or dinner. Topics include:
• Time-Based E/M CPT Coding
• Inpatient CPT Coding
• Dealing with the Difficult Person
• The Physician-Patient Relationship
• The Medical Office as a System: Team Approach
• Physician Office Compliance Plans
• Sharpening Surgical Documentation Skills
• Hot Topics in Documentation
• Mastering Accounts Receivable
• Telephone Consulting: What is Your Time Worth?
• Medical Decision-Making
• Psychiatric PPS
• Documenting Consultations
• Taming the Telephone
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| © 2008 BCE Technology. All Rights Reserved. |
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