Clinical Documentation Best Practices for Trauma Cases

Clinical documentation integrity (CDI) departments play a key role in ensuring complete and accurate documentation that complies with regulatory, billing, and reimbursement requirements. However, the high-stakes, fast-paced environment of trauma centers combined with the demands on clinical staff make it challenging to capture complete documentation of trauma cases.

The Association of Clinical Documentation Integrity Specialists (ACDIS) partnered with the Trauma Center Association of America (TCAA) to provide targeted, actionable education and insights that trauma providers need. Join the following experts from the ACDIS Advisory Board on Wednesday, July 16, from 1–2 p.m. Eastern for a deep dive into trauma-specific documentation requirements:

• Keisha Downes, MBA-HM, BSN, RN, CCDS, CCS, vice president middle revenue cycle at Beth Israel Lahey Health in Boston, Massachusetts
• Sydni Johnson, BSN, RN, CCDS, director of education for clinical documentation and denials at Banner Health in Tucson, Arizona
• Trey La Charité, MD, FACP, SFHM, CCS, CCDS, medical director for CDI and coding at University of Tennessee Medical Center (UTMC) in Knoxville, Tennessee

At the completion of this educational activity, the learner will be able to:

• Describe the role of CDI in ensuring the accuracy of the medical record
• Identify the different trauma diagnosis-related groups (DRG) and body site categories
• List specific elements required in documentation of trauma cases to ensure accurate coding and DRG assignment