Good Clinical Documentation Guide
The Good Clinical Documentation Guide
helps clinicians to recognise critical elements they need to
document to reflect the patient care process, to communicate,
report and provide clear data for research and quality of care
monitoring.
The Good Clinical Documentation Guide
provides general information about the requirements for good
documentation, and the relationship between documentation, coding
and Diagnosis Related Groups (DRGs). Specific information relevant
to 22 clinical specialties helps guide and inform clinicians
about important issues in documentation.
The specialty chapters feature:
- a range of clinical topics
- clinical profiles
- the top 5 principal diagnoses, procedures and complications
and comorbidities (ICD-10-AM/ACHI/ACS Fifth Edition) for each
relevant specialty
- documentation pointers for each topic
- AR-DRG version 5.1 information where relevant
- examples of the impact documentation has on DRG assignment
where DRG variances can be illustrated.
View
sample (gynaecology)
Please note:
If you want to order one of our products and you are located in a country licensed to use ICD-10-AM/ACHI (Ireland, New Zealand, Saudi Arabia, Slovenia, Samoa, Fiji,Romania)
please first contact the appropriate person in your national health authority to establish if a network, of other national arrangement is in place for this product before contacting NCCH.
For international orders and enquiries please contact NCCH Administration to discuss your requirements.
The guide is provided as an Adobe® Acrobat® file on CD-ROM
and features electronic navigation between topics and concepts.
The guide is printer-friendly.
Or contact NCCH
Sydney for more information
