By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM for ICD10 Monitor
CDI, when properly performed, supports the ancient physician oath, “First, do no harm.”
Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy in the telling of the patient story.
The major beneficiaries of sound documentation of patient care are the patient and the physician, in the form of effective communication for all relevant healthcare indirect and direct stakeholders including case management, utilization review/management, quality, safety, compliance, and third-party payers. Good documentation serves to further and facilitate the right care at the right time for the right reason in the right venue with the right clinical judgment and medical decision-making with the right plan of care. The clinician’s ability to understand, describe, tell, and show the complete and entire patient story supports the arrival of accurate conclusory diagnoses and appropriate treatment.
Article originally published on May 22, 2018 by ICD10 Monitor.