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DRGs
CDI: Documenting Diagnoses and Patient Safety
July 29, 2022
Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient..
How to work with clinicians for better data
August 18, 2021
Working with doctors and developing relationships doesn’t just get buy-in from clinicians – it ensures data is accurate.Nicole Draper is CDIA’s..
Why “we need to get the coding right” is the wrong message
August 6, 2021
Blaming your problems on clinical coding ignores the real culprit – your clinical documentation. “We need to get the coding right!” is a comment we..
What Is a Leading Query?
June 14, 2021
It is disheartening that there are still misconceptions about what a leading query is. In my last article, “The Query Conundrum,” I briefly talked..
Junior doctors: paperwork lackeys or key allies for CDI? Part 2
June 4, 2021
Junior doctors occupy a unique and sometimes strange position within the hospital. We are doctors. We’re called when people are sick and..
Junior doctors: paperwork lackeys or key allies for CDI?
May 20, 2021
It’s 6:30am on the general surgical ward. Three residents are preparing for the round. We’re looking up results, printing lists, and creating ward..
The Query Conundrum
May 3, 2021
To query or not query that is the question. Querying is the lifeline of clinical documentation integrity (CDI) professionals and many coding..
Who makes the best Clinical Documentation Specialist?
April 20, 2021
The CDS is the most important element in any clinical documentation improvement (CDI) program. CDI is a behavioural change process implementing..
The symbiotic relationship between your HIM and CDS teams
April 5, 2021
Strong cohesive relationships will significantly enhance the success of your clinical documentation improvement (CDI) program. Henry Ford's famous..
Bridging the gap between HIM coding and CDI professionals
April 26, 2017
Unity is strength… when there is teamwork and collaboration, wonderful things can be achieved. — Mattie Stepanek Clinical documentation..