Physician Documentation

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Physician Documentation

As part of an ongoing effort to improve quality and safety for our patients, Inova supports our physicians with information and programs on medical record documentation. Improving documentation leads to better communication among caregivers as well as improved measurement of quality outcomes based on severity of illness and risk of mortality.

Please refer to the following tools and resources to strengthen your documentation. Check back often for updates.
Training and Education  

Training by Specialty

Specialty Documentation Reference Cards (Adult/Pediatric)  

*Requires User Name/Password, found on InovaNet’s Physician page and in the Physician Brief newsletters
ICD-10 Overview/Specialty-Specific eLearning on HealthStream

Clinical Documentation Improvement Program

In 2012, Inova Health System implemented a Clinical Documentation Improvement (CDI) program to support physicians with their documentation of diagnoses, Present on Admission status and procedures for acute inpatient care. CDI positions Inova and its physicians to succeed in the future environment where quality will be the primary driver of value-based purchasing of healthcare services.

Epic Documentation Initiatives

ICD-10 News and Resources