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....

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....

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....

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....

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.

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&....

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....

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....

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....

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....

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.

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....

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....

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....

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....

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....

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."

Author: AHIMA CDI Workgroup

Source: AHIMA

Publication Date: November 2015

Infographic and glossary depicting the clinical documentation improvement journey

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....

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....

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....

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....

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....

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?

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....

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....

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.

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....

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....

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.”

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....

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....

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....

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....

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.

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....

Author: AHIMA

Source: AHIMA toolkit

Publication Date: January 2014

The content in this toolkit has been updated. More recent information is available here.

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

Author: AHIMA

Source: AHIMA toolkit

Publication Date: June 21, 2010

The content in this toolkit has been updated. More recent information is available here.