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

• Anesthesiology ICD-10 Training Plan   
• ENT ICD-10 Training Plan 
• General Surgery ICD-10 Training Plan  updated! 
• Internal Medicine and Medicine ICD-10 Training Plan  
• Medical Hospitalist ICD-10 Training Plan  updated!
• Neurosurgery ICD-10 Training Plan  updated!
• Family Practice ICD-10 Training Plan  
• OB-GYN ICD-10 Training Plan  
• Emergency Medicine Physician ICD-10 Self-Learning  
• Radiology Physician ICD-10 Self-Learning  
• Orthopedics ICD-10 Training Plan  updated!
• Psychiatric ICD-10 Training Plan  new! 
• Vascular ICD-10 Training Plan  
• Trauma ICD-10 Training Plan  
• Urology  

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.

• Overview
• Hospital-Based Documentation Support for ICD-10
• Tip Sheet - Concurrent Query
• Tip Sheet - Responding to a Retrospective Query

Epic Documentation Initiatives

• Templates and References
• Inova EPAC Approves Documentation Guidelines

ICD-10 News and Resources