1. Examples include: concurrent record review rate, concurrent query rate, query response rate, top query trends, CDS productivity EHR Optimization for Reporting Hospitals can choose from a myriad of software platforms geared toward clinical documentation improvement, case management and computer-assisted coding to Facilitate accurate, complete, and consistent clinical documentation within the health record to demonstrate quality care, support coding and reporting of high-quality healthcare data used for both individual patients and aggregate reporting. Then, paste the image into a word processing program and send it … A clinical documentation specialist (CDS) can play a key role in the success of these programs, yet many nurses are unfamiliar with this […] This small rural hospital is a 30-bed, fully paper-health dependent facility. Clinical Documentation • Clinical documentation is any information documented in a patient’s record by any healthcare provider that can impact patient quality, safety, outcomes and mortality • Only documentation from a treating physician (attending, consulting, or surgeon) can be used by coding. Clinical Documentation Improvement Strategies Identify CDI opportunities that affect various initiatives, including Meaningful Use, value-based purchasing, present on admission and hospital-acquired condition reporting Once you identify documentation gaps, think about the best solution for addressing each one– one size doesn’t fit all… In patient care organizations, accurate clinical documentation has always been important, but in today’s shifting healthcare landscape, it has become even more of a strategic imperative than perhaps ever before. Clinical Documentation Improvement Specialist 10/2011 to Current Biloxi Regional Medical Center Biloxi, MS *Assign diagnosis and procedure codes to both inpatient and outpatient charts based on specific clinical findings. Clinical documentation is at the core of every patient encounter. This policy section defines the procedures and minimum standards for documentation of Medicare/Medi-Cal Specialty Mental Health Services at any site providing those services within Alameda County Behavioral Health Care Services and its Behavioral Health Plan's Provider Network. We want to you to think about the most accurate diagnosis you can provide in each case. Clinical Documentation Improvement (CDI) Basics You can make a copy of your quiz result and email it to a recipient by pressing the Alt and PrtScr buttons at the same time while viewing your score. Scenario: You have been asked to lead a Clinical Documentation Improvement (CDI) initiative. *Ensure improved documentation to support appropriate coding and reimbursement. Module 1: Describes what clinical documentation improvement is, the importance and the challenges, medical record review and requirements, stages of CDI and the role of a CDI specialist.. Module 2: Focuses on coding, classification, coding standards, and common guidelines. Clinical documentation is the catalyst for coding, billing, and auditing, and is the con-duit for (and provides evidence of) the quality and conti-nuity of patient care. To achieve engagement, each major actor in the clinical documentation improvement process and corresponding feedback loops (including clinical, the CDIS team, HIM coders and revenue integrity) must understand how this is done, why it is strategically important and what the CDI process can do for them specifically. measures. 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