Clinical Documentation

Social determinants of health and medical coding: What to know

Andeis Robezienks for AMA Recognition of the impact that social determinants of health (SDOH) have on patients’ outcomes is growing, as is the desire to incorporate SDOH factors into patient-care plans. But awareness of an existing data infrastructure that could…

9 ways machine learning can revolutionize healthcare

By Georgina Gonzalez for Becker’s Hospital Review Machine learning can improve healthcare from streamlining administrative processes to carrying out medical and diagnostic analyses, Analytics Insight reported April 30. Here are nine areas of healthcare in which machine learning can be deployed to make…

Study Finds Female Docs Spend More Time on Documentation

From For the Record Magazine athenahealth, Inc, a provider of network-enabled software and services for medical groups and health systems nationwide, announced research insights that show significant differences in both patient interaction and appointment documentation practices between female and male…

Disability documentation in the EHR can improve care quality

By Kat Jercich ofr Healthcare IT News A recent article in Health Affairs called the electronic health record an “underrated medium” for improving care and pushed for the standardization of structures for documenting disabilities. “In medical school, we spend a lot of…

Journal excerpt: Familiarizing yourself with coding guidelines

From the ACDIS CDI Blog Because every chart is coded before being sent to payers, it’s important that CDI specialists have a working knowledge of code sets and coding rules. The inpatient prospective payment system (IPPS) final ruling, traditionally updated annually,…

HIM Challenges: The Future Looks Bright for Coders

By Angela Lima, BS, CCS, CDIP, CIC, COC for For the Record Libman Education’s survey found that 87% of respondents plan to increase their coding expertise. As you read this article, you’re probably sitting in your home office, drinking your third…

White Paper Details Technology’s Impact on CDI

From For the Record AHIMA and the Association of Clinical Documentation Integrity Specialists (ACDIS) released a new white paper that examines how rapid advancement in health care technology is driving changes to the practice of clinical documentation integrity (CDI). CDI is critical to the usability…

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