How to Review a Record: One Document at a Time I subscribe to an encounter-driven review, where one follows the provider’s critical thinking process during the encounter.
Category: Clinical Documentation Improvement (CDI)
Simplifying Clinical Validation There are many definitions for clinical validation (CV), but in healthcare, clinical validation is ensuring clinical evidence exists in the medical record for all documented diagnoses/conditions.
The Importance of Continued Education for CDI Professionals When it comes to the clinical documentation improvement (CDI) field, it’s important to remember that learning doesn’t start and stop in the classroom.
How Can I Launch a Career in Clinical Documentation Improvement? Are you a healthcare professional looking for a change? You may be surprised to learn that many clinical documentation improvement (CDI) specialists come from a variety of healthcare professions, including health information management (HIM), physician and nursing, coding, and clinical and administrative backgrounds.
Patient Safety Indicators In 2000, following publication of the Institute of Medicine’s groundbreaking report To Err Is Human, the Agency for Healthcare Research and Quality (AHRQ), was called upon to develop a standardized approach to identifying and reporting patient safety issues.
How to Effectively Manage a Remote Team Ever hear the expression, “out of sight, out of mind?” Well, that’s how many remote workers feel when their managers leave them out of the loop.
Strategies to Reduce Turnover on Your CDI Team As the cost of retaining high-quality clinical documentation information (CDI) professionals becomes increasingly higher, organizations are faced with the ongoing task to keep their existing employees happy and satisfied with their jobs.
How to Evaluate CDI and HIM Professionals for Your Team With so much healthcare talent on the market, it can be confusing for employers to know which skills and qualifications to value the most.
The Anatomy of AHRQ Quality Indicators While there are various quality indicators at work in healthcare today, likely the most well-known are the quality indicators from AHRQ, the Agency for Healthcare Research and Quality.