Clinical Documentation Improvement workshop

Speciality Public health - Skills & training

Organizer Islam Kamal Ibrahim

CME/CPD Provider National Center for Health Information - MOH


Scheduled date(s):

From 17 March 2020 To 17 March 2020

From 07 April 2020 To 07 April 2020

From 21 April 2020 To 21 April 2020

From 08 June 2020 To 08 June 2020

From 23 June 2020 To 23 June 2020

From 07 July 2020 To 07 July 2020

From 21 July 2020 To 21 July 2020

From 08 September 2020 To 08 September 2020

From 22 September 2020 To 22 September 2020


Aims And Objectives

Aim: Improve the quality of medical documentation through enhancing accuracy, completeness and validity of provider documentation. Objectives: By the end of the workshop, the attendees will be able to: - Understand the importance of good quality documentation - Know the different uses of information from medical records - Clearly understand their role and responsibility towards medical records - Identify documentation mistakes and know how to avoid them - Appreciate data confidentiality, privacy and security - Be familiar with ICD-10 codes, and what they are used for and the clinician's role - Define, select and document the principal diagnosis - Define, select and document the secondary diagnoses - Identify essential data elements required for documenting common diagnoses (e.g. diabetes, neoplasms, causes of injury, AMI … etc)


Content Outline

Content outline: - What medical records are used for & why the quality of documentation matters - Correcting written errors & documenting late entries - Confidentiality & medico-legal issues - Common documentation mistakes, their implications and how to avoid them - ICD 10 Coding • What is ICD 10 coding • Structure of ICD 10 code • What is the clinician's role - Documenting diagnoses in medical records: • Defining, selecting, and documenting the principal diagnosis • Defining, selecting, and documenting secondary diagnoses • Special situations concerning documenting principal & secondary diagnoses - Points to note when documenting specific conditions (e.g. diabetes, neoplasms, causes of injury, AMI … etc)


Target Audience

All clinicians from all specialties. (Nursing staff are also welcome according to their schedule)