Point of Entry program
The best way to get the record straight—right from the start
As more and more patients are admitted through your emergency department (ED), accurate documentation is becoming critically important. Due to the complexity of ED cases, the hectic work environment and the need to make rapid decisions, in many cases patient acuity is inaccurately reflected because there's not enough documentation of the patient's clinical situation. Staff may accurately document the injury that brought the patient in, but miss secondary diagnoses and/or pre-existing conditions. What's more, a problem list isn't usually created until the patient is moved onto the floor...if ever. Improving the quality of the clinical documentation promotes better communication and creates an opportunity to positively impact clinical outcomes.
Nuance has developed a powerful solution and a new clinical staff position to help you ensure better clinical outcomes and accurate reimbursement.
The solution: Clintegrity CDI Point of Entry program
Because documentation of critical information starts in the emergency department, the Point of Entry program starts there too—evaluating the severity of illnesses, assessing present-on-admission (POA) conditions, determining patient status (observation or in-patient), ensuring compliance with quality core measures, creating a problem list at the point of entry and enabling more accurate documentation. The Point of Entry program builds on the foundation of Clintegrity CDI and takes it even further, providing comprehensive clinical integration management.
New role: Clinical Integration Specialist
With this new solution comes a new clinical role—the Clinical Integration Specialist (CIS). This individual works closely with your clinical team to ensure all clinical observations are documented appropriately from the ED to discharge.
Your CIS is trained to:
- Perform hands-on patient assessments
- Identify and secure documentation of POA conditions
- Assist with quality indicators such as core measures and patient safety indicators
- Establish a problem list at the point of entry
- Facilitate accurate, compliant clinical documentation by providing concurrent support to physicians
- Review medical records for completeness and accuracy
- Maintain liaison with ED and in-patient case manager and CDS