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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....

Curing Inherited EHR Ailments: EHR Remediation Fixes System Issues and Better Aligns Clinical Workflow with Clinical Documentation

Author: Wieczorek, Michelle M.; Clark, Jill S

Source: Journal of AHIMA

Publication Date: September 2014



In recent years the introduction of the American Recovery and Reinvestment Act’s (ARRA’s) “meaningful use” EHR Incentive Program has encouraged more healthcare entities to chart their course toward electronic health record (EHR) system implementation, taking advanta....

Reinventing CDI: Organizations Relaunching And Reworking Data Integrity Efforts, And Coding Roles, With Clinical Documentation Improvement Programs

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2014



It’s a particularly busy night in the local hospital’s emergency department, which is running—as usual—slightly short-staffed. The on-call attending physician goes from room to room treating and diagnosing patients with typical emergency department maladies: influenza, fractured ankle, in....

CDI's Promise and Possibilities

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: July 2014




“The first job of a leader—at work or at home—is to inspire trust. It’s to bring out the best in people by entrusting them with meaningful stewardships, and to create an environment in which high-trust interaction inspires creativity and possibility.”

Improve Data and Outcomes with CDI

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: July 2014



ICD-10-CM/PCS will require significantly more clinical detail than ICD-9-CM, making clinical documentation improvement (CDI) efforts paramount for healthcare providers across the continuum of care. While CDI programs aim to substantiate claims and improve revenue streams, CDI itself shoul....

Use Data Mining Findings as a Tool to Support CDI Education

Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2014



Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

Bird’s Eye View of ICD-10 Documentation Gaps: Vendor analysis offers big picture look at nationwide documentation holes—and how to fill them

Author: Hinkle-Azzara, Barbara; Carr, Kimberly J

Source: Journal of AHIMA

Publication Date: June 2014



Increased clinical specificity is one of the greatest advantages of moving to ICD-10-CM/PCS. With specificity comes the ability to perform granular research that can help uncover significant trends and statistics to identify causes of diseases, links between diseases, and more. While heal....

Transcription Beyond Transcription: Health IT allows transcriptionists to assist with CDI, other HIM functions

Author: Carnrite, Michael; Sumner, Susan

Source: Journal of AHIMA

Publication Date: October 2012


For decades Medical transcription has been an important fixture of the health information management (HIM) department. Compiling, managing, and retaining transcribed documents as a subset of the entire patient medical record is a foundational role for HIM professionals. And while the electron....

Communication with a Side of Encouragement, Please: Effective Communication Strategies for a Smooth CDI Program implementation Transition

Author: Flood, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2012


Clinical documentation improvement (CDI) programs are spreading rapidly across the United States-and for good reason. They help facilities improve the level of documentation that goes into the patient medical record, leading to fewer errors and an overall improvement for continuity of care. Bu....

Documentation Trends in the Health Record

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: March 2012


The meaningful use program is well under way, helping providers and organizations adopt EHRs to capture complete and comprehensive documentation. To qualify for incentives in stage 1, organizations have adjusted their documentation processes to meet certain objectives and measures and will con....

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