medical coding

Medical note system could boost patient engagement, reduce documentation time

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…

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The Life of a Chart

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…

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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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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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CDI in the Outpatient Setting: Finding the ‘Hidden Gems’ of Opportunity for Improvement

By Kay Merriweather, RHIA, CCS, CCS-P, COC, CHDA, CDIP; Leslie Slater, RHIA, CCDS, CIC, CRC; and Michele Bohley, RHIA, CCS for AHIMA “If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming…

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