Clinical Documentation | Dolbey Systems, Inc.

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2 mins

Natural language processing tools take aim at value-based care through risk-sharing programs

By Bill Siwicki for Healthcare Finance News Natural language processing technology is being integrated with electronic health records and finding its way into the big data and analytics realms, often focusing on enhancing provider workflow and clinical documentation. And for the last few years, tech vendors including 3M, Apixio, Dolbey Systems, Health Fidelity, Linguamatics and…

Posted on:Jan 25, 2018
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1 min

A Call for Victory for HIM Professionals in 2018

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…

Posted on:Jan 24, 2018
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1 min

Diagnosing and Documenting Malnutrition

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…

Posted on:Jan 11, 2018
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2 mins

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…

Posted on:Jan 11, 2018
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5 mins

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…

Posted on:Jan 11, 2018
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3 mins

Amidst Opioid Epidemic, New Medical Codes May Have Muddled Data

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…

Posted on:Nov 30, 2017
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6 mins

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…

Posted on:Nov 29, 2017
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6 mins

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…

Posted on:Nov 29, 2017
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9 mins

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…

Posted on:Nov 2, 2017
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4 mins

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…

Posted on:Nov 1, 2017
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