Newborn Documentation

Accurate Documentation from the Very First Moment

We provide comprehensive education, reports, and customizable tools to link “clinical” and “code-able” language.  Ensure your newborn documentation, coding, and reimbursement reflects the true acuity of your patients.

What We Do

When your newborns’ hospital charts accurately reflect their true acuity, it drives the severity-adjustment for quality metrics and impacts your reimbursement. We have proven expertise in the unique documentation & coding requirements of APR-DRG (Medicaid) and MS-DRG (Commercial) payment models to ensure full payment for the care provided.

Our Approach

1.   Data-Driven Assessment

Using our proprietary database, we generate meaningful comparable reports and provide chart audits of final coded discharges to quantify your documentation opportunity.

2.  Interventions

We collaborate with your leadership team and medical director to address identified process barriers and develop workflow changes. We push electronically meaningful reports to leaders, highlighting performance trends against national standards to measure improvement.

• We develop customized ‘code that matter’ tools linking clinical and code-able language

• We provide tailored education to your physicians, coders, and leadership

• We educate front-line staff in real time chart assessments for opportunities

3.  Lasting Results & Long-Term Sustainability

To hold the gains, we help establish a management system to ensure daily surveillance for documentation opportunities.  We mentor leaders in process improvement to review performance, respond to new barriers, and celebrate successes

With the right insights, targeted actions, and a structure for long-term success, your newborn documentation can consistently reflect the true complexity of care, and drive the results you deserve.