59 results.
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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....
How to Help Physicians Accept CDI Programs
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: September 28, 2016
Have you ever gone to a staff meeting only to hear the news that a process you’ve been following for years is about to change? How does that make you feel? Maybe you love change and welcome any opportunity to improve a process. But maybe you are a creature of habit and the thought of a cha....
How Do CDI Programs Impact the Patient
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: July 27, 2016
We talk a lot about the impact of clinical documentation improvement (CDI) on healthcare organizations and physicians. We look at ways to reflect appropriate reimbursement and accurate quality scores, both of which are very important. But do we take the time to look at the true extent of t....
Clinical Documentation Improvement Toolkit (2016 version)
Author: Arrowood, Danita; Bailey-Woods, Linda; Barnette, Erin; Combs, Tammy; Endicott, Melanie; Miller, Jennifer
Source: AHIMA toolkit
Publication Date: July 2016
This toolkit provides many of the necessary tools and documents needed for implementing and/or maintaining a robust CDI program.
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&....
Querying Through the Chaos: How to Get Docs' Attention Amidst the Digital Healthcare Haze
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: July 2016
It wasn’t that long ago that online dating—and resultant marriages—carried a stigma. There was a sharp divide between the people who believed in meeting their loves the old fashioned way, and those who felt that online dating was a natural extension of their already Internet-centric profe....
Impact of Clinical Documentation Improvement on the International Stage
Author: Combs, Tammy
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2016
Illness doesn’t care what country or region a person lives in, and it doesn’t care the race or origin of a person. Since illness is found everywhere around the globe it only stands to reason that providers should also look beyond the boundaries of one country or patient population when re....
Transitioning from Coding to CDI Offers New Career Opportunities
Author: Endicott, Melanie
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: July 2016
The clinical documentation improvement (CDI) profession is flourishing as more organizations see the wide range of benefits a robust CDI program has to offer. The benefits of a CDI program include complete and accurate clinical documentation that supports correct reimbursement, proper repo....
Clinical Documentation for Value-based Reimbursement: Why It Takes a Village to Ensure Success
Author: Fee, James P; Clesi, Wendy
Source: Journal of AHIMA
Publication Date: July 2016
Like it or not, the transition to value-based healthcare is well underway. In January 2015, the Department of Health and Human Services (HHS) announced its Better, Smarter, Healthier campaign with clear goals and a timeline for shifting Medicare reimbursement from volume to value. Through....
Clinical Validation: The Next Level of CDI
Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2016
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
CDI is Expanding as Need for Quality Documentation Grows
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: June 23, 2016
Clinical documentation improvement (CDI) programs are quickly emerging in various areas of the healthcare arena. We now see these programs specializing both prior to and beyond the acute hospital admission. Just as healthcare doesn’t stop when a patient is discharged, health problems begin....
Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016
Author: Bonner, Dari; Fancher, Karen M
Source: Journal of AHIMA
Publication Date: May 2016
Inpatient clinical documentation improvement (CDI) has thrived since the implementation of MS-DRGs. More recently, it has grown in popularity commensurate with the implementation of ICD-10-CM/PCS. In some cases, organizations took a holistic approach to ICD-10, deliberately embedding CDI s....
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....
Documentation Detective: Seven Steps to CDI Foundational Success
Author: Combs, Tammy
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: January 27, 2016
When an architect draws up plans for a building, they pay close attention to the details of the foundation. This provides the support to the building and prevents it from crashing down at any moment. If the building later has structural damage it is easy to fix when the foundation is not i....
Using CDI Programs to Improve Acute Care Clinical Documentation to Support ICD-10-CM/PCS - Retired
Author: Combs, Tammy
Source: AHIMA practice brief
Publication Date: January 2016
Editor's note: This brief replaces the 2001 practice brief "Documentation Requirements for the Acute Care Inpatient Record, and the 2013 and 2014 versions of the practice brief "Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS."
Clinical Documentation Improvement: the CDI Journey
Author: AHIMA CDI Workgroup
Source: AHIMA
Publication Date: November 2015
Infographic and glossary depicting the clinical documentation improvement journey
ICD-10 Moves Healthcare One Step Closer to Improved Documentation
Author: Diop, Karen
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: November 2015
Change has become a constant in healthcare. With the introduction of electronic health record (EHR) systems, core measures, the “meaningful use” EHR Incentive Program, value-based purchasing, and the ICD-10-CM/PCS code sets, the healthcare industry has been bombarded by wave after wave in....
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....
More Specific Physician Documentation Needed for ICD-10-CM
Author: Burgess, Sheila
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: October 2015
The dawn of October also welcomes the official go-live date for ICD-10-CM/PCS—meaning there is absolutely no time left to waste in preparing for the additional documentation requirements necessary for successful ICD-10 implementation. Over the past several years, the healthcare industry h....
Clinical Documentation Improvement's Main Ingredient: 'Physicians First'
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: July 2015
What’s the main ingredient in your clinical documentation improvement (CDI) program? CDI programs are not new to healthcare, and depending on the organization they can look different from facility to facility. Over the past 10 years CDI programs have increased in size and scope due to cha....
It All Starts with Documentation
Author: Dooling, Julie A
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: June 17, 2015
In my April post “Quality Data Starts With Us” I discussed the importance of identifying patients correctly the first time. I think of this as Step #1 in capturing quality healthcare data for our patients.
Step #2 is in a race with Step #1, and which comes out ahe....
So What Exactly is Clinical Documentation Improvement?
Author: McDonald, Lori
Source: CodeWrite | AHIMA newsletter article
Publication Date: March 2015
There is a lot of talk in health information management these days about clinical documentation improvement (CDI). You may have questions, or you may be hearing questions around you. This short article answers three basic questions about CDI.
What is CDI?
CDI Tips Developed to Maximize ICD-10-CM/PCS
Author: Bryant, Gloryanne H.; Haik, William E; Hillstrom, Heidi
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: January 2015
Clinical documentation improvement (CDI) efforts have become a mainstay within hospitals, outpatient care facilities, physician practices, and post-acute care settings. CDI programs have a far-reaching impact on today’s data-centric healthcare system. When the appropriate level of detail....
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....
Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers
Author: Association for Healthcare Documentation Integrity; AHIMA
Source: External web site
Publication Date: July 2014
This resource kit provides a standardized approach to measuring, reporting, and improving documentation for patient safety and documentation accuracy when clinicians are responsible for document creation.
Document Like This, Not That: CDI Insights from the Physician and CDI Specialist Perspective
Author: Lo, Wil
Source: Journal of AHIMA
Publication Date: July 2014
Many HIM professionals, especially clinical documentation improvement (CDI) program participants, wonder why it can be so difficult for physicians to provide timely, reliable, precise, consistent, clear, and complete documentation in patients’ charts. It seems logical that time spent on p....
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....
Clinical Documentation Improvement Eases the Transition to ICD-10
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: July 2014
Reactions within the healthcare community to the ICD-10-CM/PCS implementation delay are varied. Many clinical documentation improvement (CDI) specialists are already well into ICD-10-CM/PCS code set education and may see the delay as a frustrating set back, while others view it as an oppor....
Selecting the Ideal CDI Physician Advisor
Author: Huff, Garry L.; Fee, James P; Clesi, Wendy; Perry, Joni; Rajappan, Melissa
Source: Journal of AHIMA
Publication Date: July 2014
Physicians are increasingly being utilized as advisors in various aspects of healthcare delivery. These include utilization review, quality resource management, and clinical documentation improvement. An effective strategy must be used to develop a physician advisor program in the area of....
Document Like This, Not That: Coders' Perspective
Author: Lo, Wil
Source: Journal of AHIMA - website
Publication Date: July 2014
A companion piece to Lo’s article in the July 2014 issue of Journal of AHIMA discusses documentation issues from the coders’ perspective. Coders face a formidable task, navigating charts and linking documentation with coding guidelines and conventions.
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....
Clinical Documentation Improvement Toolkit (2014)
Author: AHIMA
Source: AHIMA toolkit
Publication Date: January 2014
The content in this toolkit has been updated. More recent information is available here.
CDI Programs Used to Improve Quality Reporting Accuracy
Author: Chtourou, Helen
Source: Journal of AHIMA
Publication Date: July 2013
A key focus of clinical documentation improvement (CDI) programs is to identify deficiencies in clinical documentation and develop methods to ensure the complete and accurate capture of a patient’s clinical encounter. Healthcare records that are inaccurate or incomplete will compromi....
Clinical Documentation Improvement—A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs
Author: Towers, Adele L
Source: Journal of AHIMA
Publication Date: July 2013
The following is likely not a surprise to those clinical documentation improvement specialists (CDS) working day in and day out improving physician documentation. But for the record-clinical documentation improvement (CDI) is not taught in medical school. The truth is that most physicians....
Strategizing Clinical Documentation Improvement: Tracking the Right CDI Measures, Data Can Impact Multiple Healthcare Areas
Author: Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: July 2013
Clinical documentation requirements are expected to increase as healthcare systems are challenged with complex new audits, ever-changing compliance rules, and a transition to ICD-10-CM/PCS. All of these initiatives will specifically challenge clinical documentation improvement (CDI) profes....
Breaking Free of Copy/Paste: OIG Work Plan Cracks Down on Risky Documentation Habit
Author: Robb, Deborah; Owens, Lori
Source: Journal of AHIMA
Publication Date: March 2013
According to the Centers for Medicare and Medicaid Services, evaluation and management (E/M) services accounted for $28 billion in Medicare Part B payments during a one-year period.1 And of these, 8.4 percent were billed at the wrong level-either too high or too low. Chasing these potentia....
Leaders of e-HIM: Three Grace Award Finalists Share Data Integrity, Documentation Improvement, and HIE Plans and Practices
Author: Dooling, Julie A
Source: Journal of AHIMA
Publication Date: January 2013
In October 2012, AHIMA's Grace Whiting Myers Award was presented to the University of Wisconsin Hospital and Clinics in recognition of excellence in health information management (HIM). This inaugural award focused on organizations who have demonstrated effective and innovative approaches....
Holistic Coding Requires Amped Up Clinical Documentation
Author: Alonso, Paula; Love, Tammy R.
Source: Journal of AHIMA
Publication Date: January 2013
Accurately coded data does more than just provide the mechanism for appropriate reimbursement. It also tells the story of the patient, the complexity of the patient’s case, and reflects the care provided to the patient. This growing trend of “holistic coding” seems to be....
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....
Optimizing Use of Physician Advisors to Enhance Revenue and Streamline Processes
Author: Truscott, Tricia
Source: AHIMA Convention
Publication Date: October 02, 2011
Background
Physician Advisors (PA) are making their way into Clinical Document Programs (CDI) at many hospitals throughout the country, however, the question for many Health Information Management (HIM) directors and managers is “How do I best make use of this valuable resource?&rdq....
Clinical Documentation Improvement and Use of Templates and Standards
Author: Capanna, Alaina; Watzlaf, Valerie J.M.
Source: AHIMA Convention
Publication Date: October 02, 2011
One of the major obstacles physicians face when implementing an electronic health record (EHR) system is adjusting to using an electronic note. Electronic noting is often provided with the EHR through structured note templates. These templates will create the note through simple clicks of the....
CDI and Hospital Performance Rankings - Where Are Your Best Opportunities for Improvement?
Author: Belley, Susan; Garrison, Garri L.
Source: AHIMA Convention
Publication Date: September 28, 2010
Changes in reimbursement formulas, federal and state payment reforms, and other quality initiatives are challenging the way hospitals document the patient episode. Accurate capture of patient severity and post-admission complications in physician documentation not only affects payment, but al....
Clinical Documentation Improvement Toolkit (2010)
Author: AHIMA
Source: AHIMA toolkit
Publication Date: June 21, 2010
The content in this toolkit has been updated. More recent information is available here.
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