Clinical Documentation Improvement : Principles and Practice (EPUB)

Clinical Documentation Improvement : Principles and Practice (EPUB)

Through Pamela Carroll Hess

Every patient health record’s cornerstone is clinical documentation .

This book gives an objective and uniform set of principles that may be applied consistently in any healthcare organization’s clinical documentation improvement (CDI) program , along with a clear definition of the term , an explanation of its significance and examples. From patients to doctors to coding experts to reimbursement organizations , the author outlines the primary users of clinical documentation and discusses how a robust CDI program benefits each of them throughout the book .

The principles of clinical documentation are covered in Part 1 , along with how to evaluate the organization’s present documentation quality and decide whether to start a new program or enhance an existing one . The execution of the clinical documentation program is covered in Part 2 from personnel and training to querying physicians , data analysis and assuring program compliance .

Part 3 concludes by suggesting and outlining a procedure for expanding and improving a clinical documentation program . Important characteristics: explains in more detail how the switch to ICD-10 would affect the CDI process , highlighting specific coding situations . contains a fresh chapter on critical thinking for medical professionals, nurses, clinical documentation experts and coders .

detailed advice on the value of CDI program analytics for a long-term programNew content includes the most recent information on CDI technology solutions , an example query set and work plans for implementing CDI programs , the APR-DRG CDI program and managing denials . Advice on CDI for APR-DRG and quality grading that is more comprehensiveAn example presentation on physician education , engagement and strategy is available online as appendices .

Clinical Documentation Improvement : Principles and Practice (EPUB)

See also : Coding and Reimbursement for Hospital Inpatient Services, 4th Edition(EPUB)