These days, clinical documentation improvement is on everyone’s mind. As hospital’s focus on ramping up documentation to prepare for ICD-10, the demand for CDI specialists continues to grow. In fact, ...

According to Donald Berwick in a recent Wall Street Journal article, “…the formula for ACO success is clear: keep quality high, save money by improving - not by restricting - care, and remain ...

Clinical documentation improvement (CDI) are three buzz words in today's healthcare lingo that have come to signify a means of achieving better data quality that leads to more accurate reimbursement ...

Interest in ambulatory clinical documentation improvement continues, as does the confusion about what such an approach can and cannot accomplish. In a previous piece, I discussed what ambulatory CDI ...

Staff at Montefiore St. Luke’s Cornwall in New York City was faced with a complex and timely physician query process. Queries often would be left unanswered, as providers were challenged by varying ...

There are computer products that optimize workflows for coders and clinical documentation specialists. New computer-assisted physician documentation systems leverage artificial intelligence and ...

It’s a phrase that we all hear, and repeat, regularly, but it may be no truer than at rural and critical access hospitals. In these environments, the health information management (HIM) person may do ...

Healthcare system survival pivots on many metrics, but the ability to generate revenue and to evidence high quality of care are two of the most essential. At the center of both metrics is the clinical ...

Rebecca Crane, 33, a Western Springs resident, is a clinical documentation specialist, and has always worked in the medical field because she enjoys helping people. She answered these questions inside ...