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 »
Last week more than 700 CDI professionals attended the 4th Annual ACDIS Conference at the Hilton Walt Disney Resort in Orlando. From the physician advisor preconference, to the poster session, and the terrific vendors in the exhibit hall to the three tracks of educational sessions, it...Read More »
Hospital acquired conditions (HAC): The phrase seems simple enough to understand. These are conditions one acquires while in the hospital, right? Like most phrases included in the healthcare vernacular, however, discussion of HAC contains various levels of detail that can be difficult to...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.