Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the Medicare Conditions of Participation requires of your medical records.
But many hospitals struggle to achieve compliance in this area. And falling short doesn't just affect quality and...Read More »
Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for...Read More »
CDI Week is almost upon us and with it, a slew of activities, appreciations, and—most importantly—stories. We often speak of the patient’s story in CDI, being faithful to the record, and getting the details right: if we do those things, we hope the patient can have a happy ending. Physicians,...Read More »
I recently had occasion to stop and think about how I approach a chart for a clinical documentation review. For me, it has become an almost instinctual process, so I found it instructive to examine my process in a more systematic...Read More »
Join us next week on Tuesday, August 22 to Thursday, August 24 for a special virtual event, ACDIS Encore: Clinical & Coding Online, featuring sessions recorded live during the 2023 ACDIS national conference—the entire Clinical & Coding...Read More »
Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the Medicare Conditions of Participation requires of medical records. But many facilities struggle to achieve this seemingly simple task. Falling short doesn't just affect quality and patient care. Auditors...Read More »
Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.
It’s time to respond to our third Council survey: The 2023 CDI Week Industry Survey! To receive credit for the survey, make sure to complete your name and email when prompted to do so by the survey. As a reminder, Council...Read More »