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Improvement in Treatment Documentation at SMDC Rehabilitation Locations, Duluth, Minnesota, Region

by Helgeson-Britton, Pam

Abstract: Paper-based documentation systems existed at 5 out of 10 SMDC Health System rehabilitation locations, resulting in inefficient interprovider communication, inconsistent processes, waste, and compliance risk. The lead time to complete the documentation from initial visit to discharge was more than 31 days. Initial patient evaluations were dictated and transcribed. The documentation often did not meet Medicare documentation compliance standards because the standards were not widely understood or practiced. SMDC launched a project to eliminate paper treatment documentation, reduce its Medicare documentation compliance error rate, establish a centralized location for all therapy documentation, and reduce physician complaints regarding inadequate reporting from the current baseline of three times per month to less than one time per month.

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