Clinical Documentation

Chart Conundrums: Desperately Seeking Clinical Validation

By Angie Dibble, RHIT for For The Record Sepsis, encephalopathy, malnutrition, and acute renal failure are examples of diagnoses that often prove vexing for coders and clinical documentation improvement (CDI) specialists. What if the sepsis diagnosis is based on “technically meets sepsis criteria” because a patient with a urinary tract infection has an elevated white blood…

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How to Improve Clinical Documentation

As health systems work to get the most from their physicians’ EHR charting, experts say it’s important to focus on the right metrics while working toward greater buy-in from doctors. By Mike Miliard for Healthcare IT News Hospitals and health systems trying to survive and thrive under value-based reimbursement realize that optimal clinical documentation is…

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Sticky Query Situations

By Selena Chavis for For the Record Clinical documentation improvement (CDI) processes have made significant inroads in recent years. Now a mainstream strategy within any forward-looking hospital, CDI teams are critical players in the greater quality management picture as it relates to successfully positioning for value-based care. Not all CDI workflows and processes are created…

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Discussing Second Level Reviews in CDI

Article by Marina Kravtsova. This article was originally published on the Journal of AHIMA website on Sep 29, 2017 and is republished here with permission. Over the past nine months, the clinical documentation improvement (CDI) team that I represent has been recruited to perform so-called second level reviews. All cases presented to the CDI team for second level review thus…

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What Are The Top IT Security Challenges Facing Hospitals?

By Jim Keener for Health IT Outcomes A recent survey of healthcare executives revealed employee awareness as their greatest cybersecurity concern. Even if comprehensive educational programs are already in place, it can be difficult for hospital administrators to stay on top of the latest IT security challenges and solutions. This is partially due to how busy physicians…

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Cancer moonshot head recounts exchange with Epic’s Faulkner

By David Pittman, With help from Darius Tahir for Politico BIDEN, EPIC TALK MEANING OF ‘EASY TO UNDERSTAND’: Former Vice President Joe Biden took to task an Epic executive who questioned during a January meeting of the Cancer Moonshot why patients should have their full medical record, a Biden aide recounted Tuesday. Epic CEO Judy Faulkner…

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Bridging the Gap between HIM Coding and CDI Professionals

Article by Steven Robinson, MS, PA, RN, CDIP. This article was originally published on the Journal of AHIMA website on April 26, 2017 and is republished here with permission. Unity is strength… when there is teamwork and collaboration, wonderful things can be achieved. —Mattie Stepanek Clinical documentation improvement (CDI) professionals have a worthy task to help identify…

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Cyberattack on Medical Software Shows Industry Vulnerability

By John Lauerman and Jeran Wittenstein, with assistance by Joshua Fineman and Saritha Rai for Bloomberg Technology Many doctors still can’t use a transcription service made by Nuance Communications Inc. three weeks after the company was hit by a powerful, debilitating computer attack. Hospital systems including Beth Israel Deaconess in Boston and the University of Pittsburgh Medical Center…

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Dolbey Systems, Inc.