University Hospital Fundación Jiménez Díaz Clinical Documentation Service collaborates with the IIS-FJD, performing all tasks required to support research carried out by groups belonging to the institute. This includes assembling, maintaining, and overseeing the FJD clinical database and drafting reports on article publication, seminars and conferences, doctoral theses, etc.

Staff

Service head

  • José Miguel Arce Obieta

Physicians

  • Milagros Polo Ordoqui
  • Antonio Robles Albarrán
  • Pilar Mielgo Beller

Section head

  • Mónica Díaz Herrero

Other personnel

  • RNs
  • Document technicians
  • Administrative staff
  • Porters

Activities - Clinical Documentation

  • Maintain and oversee movement of paper-based clinical records.
  • Copy clinical documentation.
  • Maintain the master patient file.
  • Maintain electronic medical records.
  • Manage clinical documentation from other hospitals.
  • Prepare clinical records (surgery waiting list).

Activities - Clinical Coding

  • Clinical coding.
  • DRG grouping (AP/APR).
  • Review of clinical databases: inpatients, major outpatient surgery, and day-stay hospital.
  • Quality control for coding.

Activities - clinical information

  • Review the Minimum Basic Data Set (MBDS).
  • Submit the MBDS to Madrid regional authorities and to the National Statistics Institute.
  • Provide support for clinical committees: clinical documentation, mortality, complications and readmissions, and the functional unit on health-care risk management.
  • Review of clinical information: inpatient case mix, major outpatient surgery and day-stay hospital, complexity indicators, management of inpatients, major outpatient surgery and day-stay hospital, and indicators of mortality, complications, and readmissions.
  • Clinical-management support for hospital departments: reports concerning the clinical management of these services and review of care quality.
  • Support for hospital management: clinical and care-quality management reports.
  • Drafting of reports on care quality and patient safety.
  • Revision of indicators established by the Quality Observatory and AHRQ.

Certificates / Projects / Studies

  • ISO 9001:2008 quality certification granted to the Clinical Documentation Service.
  • Standardization of clinical documentation for use in a multi-center information system supporting clinical management.
  • Evaluation of APR-DRG as a system used to manage and analyze inpatient activity in the Fundación Jiménez Díaz.
  • Study of risk-weighted and diagnosis-based capitative systems.
  • Design of methodological tools to improve care quality.
  • Early Warning System - Acute Renal Failure Project.
  • Assessment of natural language processing systems to support coding required under ICD-10-ES.

Scientific output

The service also publishes scientific studies and collaborates in teaching initiatives:Department of Preventive Medicine, Public Health, and the History of Science. Medical School, Universidad Complutense de Madrid.