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Investigative Approach: How Clinical Documentation Teams Improve Communication, Documentation Outcomes and Patient Care

Author: Robinson, Steven

Source: Journal of AHIMA - website

Publication Date: December 29, 2016



Clinical documentation programs’ success is a result of the healthcare team keeping a constant vigil on communication while operationalizing outcomes and instilling provider support. Patient care is largely dependent on accurate communication among the healthcare provider team. In a....

Clinical Validation: the Next Level of CDI (December 2016 update)

Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne

Source: AHIMA practice brief

Publication Date: December 2016


One of the more challenging tasks for both coding and clinical documentation improvement (CDI) professionals is clinical validation. This is a relatively new responsibility that has evolved as CDI programs mature and CDI and coding professionals advance their knowledge and collaboration on clin....

CDI: A Cog in the Wheel of Information Governance

Author: Downing, Katherine

Source: Journal of AHIMA

Publication Date: July 2016



Information governance (IG) is an emerging discipline in healthcare that focuses on how an organization ensures information is complete, accurate, trustworthy, and usable. The goal of information governance is to enable organizations to utilize a valuable strategic asset—information&....

Recognizing the Characteristics of Quality Documentation

Author: Combs, Tammy

Source: Journal of AHIMA

Publication Date: May 2016



When we take a bite of our favorite food we can easily determine the quality by relying on what our senses tell us. The look, smell, and taste are all clues to the quality that was put into preparing the meal. If it looks undercooked or has mold on it, smells foul or tastes bitter, we kno....

Measuring CDI Productivity

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 23, 2016



When calculating the productivity guidelines for a clinical documentation improvement (CDI) program it is important to remember both quantitative and qualitative perspectives. Sometimes it is very easy to focus solely on the quantity of reviews that are performed. If the quality of those r....

Understanding HIM’s Impact on Quality at the National Level

Author: Munn, Catherine; Backman, Cecilia; Costello, Stephanie; Wise, Lee A; Westhafer, Kathy J

Source: Journal of AHIMA

Publication Date: October 2015



The future of healthcare continues to evolve with the introduction of alternative reimbursement models. The industry is moving from traditional fee-for-service models to those focused on quality of care and documented outcome improvements. The Patient Protection and Affordable Care Act of....

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