Nick van Terheyden, MD, and Paul L. Weygandt, MD, JD, MPH, MBA, CCS, FACPE provide insight into innovative technologies, including primary real-time documentation methodologies, computer-assisted physician documentation, dynamic problem lists, and computer-assisted coding. They address ...

Nancy Rae Ignatowicz, RN, BS, MBA, CCDS explains how one hospital system chooses specific CDI  data, to present depending on the specific audience (administrators, providers, etc.), and used it to obtain the resources and support needed to drive improvement. This presentation will include...

Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA, and Michael Yanuck, MD, FAAFP will chronicle their EHR journey to illustrate how electronic notes quickly snowballed, detracting from new information while  becoming unreadable to other physicians. Best practice solutions and approaches with specific...

Vicki Sullivan Davis, RN, Clinical Documentation Improvement Manager at Cone Health System at Alamance Regional in Burlington, N.C., provides participants with the tools to achieve excellence while confidently managing their CDI team. Davis outlines qualities a good leader should possess   and...

Nancy A. Entwistle, MPA, RHIT, CCDS, CCS, ACE, AHIMA-Approved ICD-10-CM/PCS Trainer Manager, Documentation Improvement and Clinical Coding Emerson Hospital in Concord, Mass., helps the new CDI specialist understand the components needed to effectively code the record, identify what he or she...

Attached is the General Session PowerPoint presentation “Avoiding a False Claims Action: A Legal Perspective on Documentation Issues”  by Ray M. Shepard, JD, partner in the Maryland law firm of Smith, Gildea & Schmidt, LLC.

Attached is the PowerPoint presentation “Understanding and Implementing the New Definition of Malnutrition,” by Trey La Charité, MD, physician advisor for the clinical documentation integrity project and coding at the University of...

Attached is the PowerPoint presentation “Encephalopathy and Brain-Related SOI”, by Cindy Pritchett, RN, BSN, CCDS, clinical documentation improvement consultant for MedPartners HIM.

Attached is the PowerPoint presentation, "CHF: A Clinical and Coding Perspective", by Garry L. Huff, MD, CCS, CCDS, president/CEO of Huff DRG Review services, and Carla A. Sueta, MD, PhD, FACC, ...

Attached is the PowerPoint presentation "Yes SIRS, No SIRS, and Deep Cleansing Breaths: Sepsis and Respiratory Failure", by Michelle Fournier, RN, MN, CCRN (Ret.), AHIMA-Approved ICD-10-CM/PCS Trainer, a director of clinical...

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