Clinical Documentation

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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