An ACDIS member recently recounted a disappointing story regarding her facility CDI program implementation. Essentially, the nurses performing concurrent queries disagreed with the coders at nearly every turn. I’m sure many of you can relate to this...Read More »
The role of the clinical documentation specialist has been in a state of flux for the past few years. We wear many hats including that of nurse, coder, teacher, auditor, statistician, politician, and sometimes therapist.Read More »
Clinical documentation improvement specialists continue to have trouble discerning between leading and non-leading physician queries. The question often comes down to an understanding of the various previous “lives” of professionals.Read More »
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
Communication is defined in the Merriman-Webster dictionary as a verbal or written message, exchange of information, or a process by which information is exchanged between individuals through a common system of symbols, signs,...Read More »
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
A clinical documentation improvement (CDI) specialists’ focuses on educating physicians on the merits and material benefits of complete, accurate, and effective medical record documentation on the practice of medicine.Read More »
The case mix index is up and admissions continue to rise. You’d think this was wonderful news. Yet, the facility administration complains that reviews are down and queries are low. You don’t have to be a math genius to know that something here does not...Read More »
A recent hospital audit of 300 medical records turned up some not too surprising facts about physicians. The doctors are still not documenting appropriately, their handwriting is illegible, and the discharge summaries are inadequate.Read More »
