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For HIM and CDI professionals, 2018 looks to offer a gift of the tremendous opportunity for success. By Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS for ICD10 Monitor For movie buffs, the film Darkest Hour offers a tremendous view into the early days of World War II, when the fate of Western Europe hangs on…
By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor Dieticians’ findings must find their way into the medical record to achieve proper care and coding. Diagnosing malnutrition is not diving for dollars. Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty…
New research finds patients could benefit if they are invited to co-produce medical notes with doctors rather than simply reading them. By Jeff Lagasse for Healthcare IT News Encouraging patients to help write and add notes to their personal medical charts — a task typically handled only by medical professionals — may help patients feel…
By Angie Dibble, RHIT for For the Record Remember when we thought of medical charts as inanimate objects, safely tucked away on a dusty shelf in a paper mill known as “Medical Records”? In my prior life, the one I innocently enjoyed before working in health information, I believed all medical charts were somehow pure…
By Naseem S. Miller for Orlando Sentinel The number of babies who were exposed to opioids in the womb jumped by 200 percent in Florida between 2015 and 2016 — to more than 2,500 cases — the biggest spike in the past decade, according to state data. But the number of newborns statewide who were…
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…
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…
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…
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…
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…