EHR documentation can be dictated by billing rules and legal requirements, or by the physicians’ need to describe his or her patients and provide quality care, according to the ...Read More »
Since these “intros” were my idea, everyone said that I should be the first person in the proverbial hot seat.
Because I consider myself a writer (I spent about a decade writing and editing my hometown newspaper and recently earned my master’s degree in...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 »
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 »