Clinical Documentation

Understanding the Importance of Clinical Validation Queries

By Cheryl Ericson, RN, MS, CCDS, CDIP for ICD10monitor Clinical validation queries have been recommended for almost a decade, yet many clinical documentation integrity (CDI) and coding professionals continue to struggle with crafting these types of queries. The Guidelines for…

What Does Nurse Recruitment Look Like Now for CNOs?

By G Hatfield for HealthLeaders As the nursing shortage looms, new expectations give way to new recruiting strategies. KEY TAKEAWAYS In the face of a daunting workforce shortage, health systems are struggling to recruit and retain the best talent. Nurse…

Leadership Rules – Top Strategies and Skills for HIM Leaders

By Susan Chapman, MA, MFA, PGYT for For The Record HIM continues to evolve, especially as technological advances like artificial intelligence (AI) are rapidly infiltrating health care. As the health care industry experiences this unprecedented transformation, HIM leaders offer their…

Upcoding a key concern for coders in 2025, survey says

From ACDIS CDI Strategies Upcoding—when higher-level codes are assigned than are justified to increase reimbursements—will remain a major ethical dilemma in 2025 for coders, according to survey data released by Black Book Research. Of more than 4,000 surveyed health information management…

Coding for Gender-Affirming Health Care

By Susan Chapman, MA, MFA, PGYT for For The Record Gender identity is how individuals perceive themselves, be it different or the same as the sex they were assigned when they were born.1 Gender identity differs from gender expression in…

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