When visiting a patient in the hospital, an attending physician, who is not a hospital employee, speaks to the nurse caring for the patient to get information that the patient may be unable to provide or is not documented in the chart. Would this be considered an "independent historian" for the data element? After seeing the patient and reviewing the chart, the attending physician then discusses the care plan and any changes with the nurse. Would this be considered "discussions of care management with a qualified health care professional/appropriate source?" ...
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Article Overview
The article considers questions about independent historians and discussions of care management in the context of an attending physician's interactions with nursing staff. It addresses the roles of care-team relationships, patient-setting context, and the type of information being shared.
Why This Topic Matters
Understanding how clinical conversations relate to documentation and medical decision-making data elements can help clinicians and coding professionals assess these concepts across care settings.
What You Will Learn
- How the article frames independent historian considerations in relation to nursing staff
- How care-management discussions with health care professionals are considered in the article
- How inpatient, observation, and nursing facility contexts relate to these topics
- intended_audiences
Who Should Read This
- Physicians
- Medical coders
- Clinical documentation and compliance professionals
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