Dec 1st, 2014
The CDIS isolates common problems to strengthen the overall patient record. by Nancy Reading, RN, BS, CPC, CPC-P, CPC-I Clinical documentation is integral to every inpatient or outpatient encounter to provide continuity of care and a legal record of a patient’s health status. Reimbursement, compliance, and specificity are likewise tied to documentation-driven coding. The role ...
In Audit
Jul 1st, 2014
Queries (also know as clinical clarifications, documentation alerts, or documentation clarifications, among other names) are an essential component of any clinical documentation improvement (CDI) program. A query is a communication and education tool that prompts physicians to provide detail about under-reported conditions found in the medical record. Queries may address several documentation areas...
Aug 1st, 2011
Capture conditions with clear, concise documentation to increase reimbursement and decrease risks. By Karen Stanley, MBA, RN A clinical documentation improvement (CDI) program is a great way to ensure your facility is capturing all relevant details of a patient/provider encounter. This, in turn, boosts clinical and financial outcomes. CDI programs began in the 1990s. Most ...