Only 1.5% of the nearly 3,000 nonfederal hospitals in the United States reported the use of a comprehensive electronic medical record (EMR) system, according to a March report published in the New England Journal of Medicine. With so few facilities employing EMRs, why should CDI program managers...Read More »
The reason for assignment of a certain principal diagnosis is occasionally incomprehensible. First, consider what a principal diagnosis is. It’s the condition or group of conditions that, after workup, the physician determines led to the patient requiring...Read More »
In full disclosure, I got through nursing school by working at Disneyland. Disney has all their employees go through a customer service program. Controlling crowds, maintain safety, even asking for payment of high-ticket items must be done...Read More »
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 »
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 »
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 »
