Clinical documentation

1. Clinical Documentation
Keeley Burns
Specialist Nurse
ANUM ICU
24th June 2019

2. Legality
Incidence
Financial
USES OF CLINICAL DOCUMENTATION

3. PRIVATE HEALTHCARE AND FUNDING
Funding
Assumed Complexity
Coding

4. The hospital is funded solely by reimbursements from the health
funds.
Everything you document has an effect on the assumed
complexity of the patient
Health Information Services CAN NOT CODE from results and
treatment
PRIVATE HEALTHCARE AND FUNDING
Funding
Assumed Complexity
Coding

5. ➤ Translate results and evidence
➤ Relate treatment DUE TO…
➤ Document and justify commencement, alteration or
adjustment of therapeutic treatment
➤ Be specific
TAKE-HOME MESSAGES

6. PATIENTS ARE COMPLEX!

7. QUESTIONS?

8. THANK YOU