clinical documentation improvement examples

He is to follow-up with me tomorrow. A consultant from Beacon Partners explains why. He should document when the patient should return for a follow up visit. > Resume examples > Clinical Documentation Improvement Specialist Resume. Improving clinical documentation quality. Cardiovascular: Hypertension •Configure EHR structured fields, alerts, and … Instruct the provider to include this information in the exam. and rales to bilateral lower lobes. Due to his history and new symptoms, I am concerned Right Knee: Normal Instruct the provider to document all of his concerns. Prosthesis presents a high risk for infection. Clinical documentation improvement (CDI) programs have evolved from being an informal part of the process to becoming the backbone of the facilities financial viability. slight enlargement of spleen Truth time – how thorough is your physicians’ documentation? This patient is a 72 year-old white male who states that 4 Clinical Documentation Improvement Newsletter Vol 1, Issue No. Because the patient has a history of MRSA and presents with skin lesions, the provider would have a concern for infection. Because of this, clinical documentation improvement (CDI) plays a key role across … His PMH, indicated he had skin lesions about 18 months ago. Cardiovascular: Popliteal is diminished, pedal pulse is normal. is widowed, and in generally good health for his age. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. Fatigue, 780.79 Clinical Documentation • Clinical documentation is any information documented in a patient’s record by any healthcare provider that can impact patient quality, safety, outcomes and mortality • Only documentation from a treating physician (attending, consulting, or surgeon) can be used by coding. Clinical Documentation Improvement (CDI): The Secret to Painting a Clinical Masterpiece Speakers Daxa Clarke, MD Amy Sanderson, MD Medical Director, CDI & UM Physician Advisor, CDI Program Phoenix, AZ Boston, MA Lucinda Lo, MD Sheilah Snyder, MD Physician Advisor, CDI Program Physician Champion, CDI Program Philadelphia, PA Omaha, NE. A clinical documentation improvement program is a dedicated team of healthcare professionals that will assure that the medical record documentation reflects an accurate picture of the patient's diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care. Required clinical documents, once entered into the medical record, become part of a legal document. Below are three successful clinical examples of quality improvement in healthcare covering a wide range of issues facing many health systems today. Inform provider the importance of coding for history of MRSA when it could impact the presenting problem of the patient. Then, paste the image into a word processing program and send it … PLAN: In summary, a clinical documentation improvement program is a comprehensive, multi-disciplinary effort that includes the medical staff, clinical documentation specialists, inpatient coders, and CDI physician advisors. Because the patient presents with knee pain, the provider would perform a more thorough exam than what is documented. If you need a little help, click on the hints provided. He documents elevated glucose but he does not document that it is uncontrolled. The type of diabetes must be documented. started "feeling bad" he complains of generalized fatigueand By Adele L. Towers, MD, MPH. AHIMA’s advanced workshop prepares CDI professionals to train others in industry best practices. Gastrointestinal: Normal bowel sound x4, No tenderness, I find he had MRSA with multiple skin lesions, however was treated timely and aggressively and there After the documentation is translated into the alpha-numeric codes submitted in claims, the data are analyzed to generate results on quality and clinical outcome measures, in addition to payments. He worked in his garden last weekbending No need to think about design details. discussed all of this over the phone with his daughter and she is in agreement. Essential for patient safety and care, quality ratings, accurate reimbursement and reduced physician queries, CDI programs are required and necessary for consistent and complete documentation. He also states he is having pain in his Here is a job description example that shows the major tasks, duties, and responsibilities that clinical documentation specialists commonly perform: up today. Endocrine: Diabetes, EXAM: With accurate clinical documentation, a medical billing company can help healthcare providers submit valid claims for reimbursement. Identification of Problematic Physician Documentation … The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. Date of Exam:  06/22/2010 See if you can identify the 33 missing elements that would enhance the documentation for this note. He states he is getting worse and comes in for a checkup. RX: For tonight only increase Glucophage to two tablets. Inspection and ROM of the bilateral upper and lower extremities Continue home meds. LABS: Glucose, CBC, CMP, UA with C&S, and sputum culture. Develops strategies and provides suggestions to ensure program success, Works collaboratively with physicians, nurses, and ancillary providers to accurately represent each patient's signs, symptoms, diagnoses, and treatment plan, Acts as a liaison between the technical and clinical coding functions, Educates health team colleagues about coding and data management including role responsibilities, tools, methodologies, and anticipated outcomes, Partners with HIM and Revenue Cycle professionals in third party payer DRG audits and appeals, Establish client relationships with key individuals such as but not limited to Director of Health Information Management department, Vice President of Revenue Cycle, Director of Clinical Documentation Improvement department, CIO and / or Practice / Office Managers during the implementation and post implementation process, Acts as a primary, detailed, hands-on expert for the product during the implementation and post implementation process, Work flow analysis, process redesign, user acceptance testing, training, go-live support and analytic review, Reviews sales assessment document and any other client information to determine scope of the project and potentially any implementation concerns, Participates in introduction call, scoping visit and discovery visit to review current workflow, analyze operational processes, and determine future workflow and operational processes, Addresses concerns to Project Manager, Director of Product Management and Vice President of Implementations, Technical Engineering and / or any other team appropriate within, Optum to optimize how the product and / or services will best integrate into the client’s processes and systems, Demonstrates clearly and effectively Optum’s Enterprise Computer Assisted Coding (CAC) application (hospital and professional), Coding Reimbursement Module and / or Clinical, Documentation Improvement Module and addresses client concerns and questions, Participates in weekly project meetings with members of the implementation team (internal and external) to review the project task plan and evaluate progress; provides input throughout the implementation and post implementation process, Documents and verbally communicates task status, progress to facilitate a smooth implementation, and / or any risk associated with the project, Primary organizer and trainer for user acceptance training and testing (UAT), Bachelors of Science Degree in Health Information Management, Healthcare Informatics, Clinical Documentation Improvement, Nursing, OR active RN license, 5 years of experience functioning as a software product and / or domain expert in large health care systems, healthcare practice management or the managed care space, 5 years of work experience in Clinical Documentation Improvement, Experience in managing large-scale projects where deadlines are met on or ahead of schedule, Experience in customer service skills (direct on-site client representation), Ability to travel, including overnight, as needed up to 80% of time, Certified as an RHIA, RHIA, RN, CCS, or CPC, Proven leadership ability across all levels of an organization, including executive level (CxO), Time management skills; ability to multitask and manage competing priorities, Strong written and verbal communication skills that can effectively communicate with a diverse workforce, Executive presence and interaction skills, Strong interpersonal and negotiation skills, with a high degree of self-motivation and ability to work independently through effective influencing, Strong process orientation, problem solving and troubleshooting skills and a firm commitment to quality, Maintains up-to-date working knowledge of Medicare/Medicaid rules and regulations regarding CDI, basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement, Develops and implements CDI strategies, capitalizing on facility best practices. Give comparison as to his health when well. Clinical Documentation Improvement Joy presents for a recheck on her simple chronic bronchitis. Continue home meds. Facilitates orientation of new CDI staff, Monitors and analyzes trends in the CDI process. Well healed incision from previous surgery days ago he Help identify problems, offer solutions and participate in resolution, Foster respect for privacy by maintaining confidentiality in all phases of the work, Demonstrate knowledge of and perform the duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, State and Federal Quality Improvement Organizations, Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), Contribute to ongoing department information sharing and promoting knowledge and skill development, Demonstrate knowledge of resource management in an effort to decrease resource consumption while adequately maintaining effective operations, Maintain current professional credential (s) related to clinical documentation improvement and submits a copy to Human Resources in a timely manner, Initiate & participate in formal and informal, required and voluntary continuing education opportunities; enhancing professional growth, maintaining CEU’s required for licensure and/or certification, and enabling adherence to changes in regulatory requirements, Educate all members of the patient care team on documentation guidelines on an ongoing basis, Consistently adheres to instructions from Superiors (Supervisor/Manager/Director etc) and follow the chain of command, Have sound knowledge and understanding of pathophysiology of disease processes and their management, Have knowledge of age-specific needs and elements of disease processes and related procedures, Understand care delivery documentation systems and related medical record documentation of patient’s care reflective of the severity of the patient’s condition, Have assertive personality traits to facilitate ongoing physician education, Have ability to work independently in a time oriented environment, Be computer literate and familiar with operation of basic office equipment, Be willing to learn and consistently take instructions from Superiors (Supervisor/Manager/Director etc.) Integument: Skin lesions Psychiatric: Normal, age appropriate Appropriately manages resources, Oversees relationship management with payers and network providers, Provide strategic planning and direction for the development and enhancement of CDI program services through the National CDI Center of Excellence. Lost in Middle America 3. Certified Documentation Expert – Outpatient, Certified Professional Compliance Officer, May Clinical Documentation Improvement workshop. He does have a prosthetic joint. Appendectomy when he was a teenager, TURP 12 years ago, TKA 5 year ago. Experience in both areas preferred, Use your extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines, Verify clinical documentation against final coding and modify CDI technology entry in order to report valid CDI outcomes, Reviews clinical issues with the coding staff to assign a working DRG, Participate in patient care conference/case conferences to identify needs for clinical documentation, Maintain current skill set with regard to government regulations, compliance and reimbursement guidelines, Expected to keep abreast of new legislation and regulations that affect CDI, Provide input for reporting of metrics and measures of CDI program activity to hospital executive and medical leadership, Maintains personal and professional education and growth, Responsible for maintaining continuing education credits as required by credentialing organization, RN Required. 5’9", Wt. Privacy Policy | Terms & Conditions | Contact Us. Related Terms clinical decision support system (CDSS) A clinical decision support system (CDSS) is an application that analyzes data … Concurrent and retrospective reviews ; Work with physicians to improve the documentation of inpatient medical records. For example, codes reflecting severity of illness and risk of mortality are used to risk-adjust data in order to avoid penalizing clinicians who care for sicker patients. No history of a heart This additional information provides a better understanding of how bad the patient feels. Develops and implements action plans to maximize the CDI program in the division, Facilitates the development and review of division/facility CDI plans to ensure compliance with internal audits, state and federal regulatory requirements. or his cough or SOB worsens during the night. GI: GERD, controlled with meds CDI programs can have multiple positive outcomes, including, but not limited to: Standardizing care across teams; Reducing claim denials and increasing reimbursements; Managing procedure quality and bench-marking; Improving patient throughput and satisfaction; Developing more thorough, accurate procedure notes; Sites that utilize … Always … ), Working with their director, reviews, revises, and/or implements departmental policies, procedures and/or guidelines, Monitors achievement of CDI key performance indicators and initiates and executes action plans as appropriate, Minimum three years of supervisory or management experience in a health care setting required, Health Information Management department experience preferred, Oversee and act as resource for Clinical Documentation Improvement departments across Conifer Health including monitoring daily activity and completion of performance and metric reports, Test, interview, hire and retainCDI staff, Lead meetings with team leads and CDI l staff Account for timekeeping in all systems for all initiatives, Development of team goals and plans ensuring alignment with national goals and yearly evaluations, Responsible for the supervision and coordination of CDI process including implementation and adherence to best practices and principles, Knowledge of disease pathophysiology and drug utilization, Effective written and verbal communication skills including report writing and presentation skills, Ability to maintain an auditing and monitoring program as a means to measure query process, Skilled in performing quality assessment/analysis, Three (3) or more years’ experience in CDI, Preferred: Minimum: Two (2) years supervisory experience, Coding Technical Skills - regulatory coding (ICD-10-CM, ICD-10-PCS, ICD-9-CM, MS-DRGs, POA Assignment) and associated reimbursement knowledge, Critical thinking - actively and skillfully conceptualizing, applying, analyzing, synthesizing or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning or communication as a guide to belief and action, Effective Operational Decision Making - relating and comparing; securing relevant information and identifying key issues; committing to an action after developing alternative courses of action that take into consideration resources, constraints, and organizational values, Initiative – independently takes prompt proactive steps towards problem resolution, Stress tolerance – maintaining stable performance under pressure or opposition; handling stress in a manner that is acceptable to others and the organization, Planning and Organization - proactively prioritizes initiatives, effectively manages resources and keen ability to multi-task, Minimum 3 years' health care management/leadership experience required, Minimum 5 years' recent inpatient hospital coding experience required, Work with Revenue Cycle leadership to develop, implement, and oversee effective and consistent operational policies, processes, tools, and educational materials within all CDI functional areas, Manage the operational performance and productivity of the system-wide Clinical Documentation Improvement program against pre-defined policies and goals/targets, Collaborates with staff, leadership across the Revenue Cycle organization, clinical departments, and related stakeholders to identify and track trends in clinical documentation and resolve noted areas of improvement, Maintain a strong background in APR-DRGs, MS-DRGs, ICD-9 codes, ICD-10 codes, coding guidelines and coding clinics, Maintain a current working knowledge of Medicare/Medicaid rules and regulations along with knowledge of other diagnosis related group (DRG) payer sources, Maintain current working knowledge of CDI, present on admission (POA) and basic coding, as well as trends and developments in the area of CDI, Create a work environment for employees through team building, coaching, constructive feedback, work delegation, personal example and goal setting that encourage creativity, open dialogue on work issues, professional growth, and a consistent, high level of performance. After questioning further, Left Knee: Walks with slight limp. Zantac 230 Lbs, BMI 34 Temp. This information helps determine if the condition is acute, traumatic, chronic or degenerative. Bachelor's Degree required, In addition to education, recent 3 to 5 years of well-rounded medical or surgical acute care nursing and/or critical care nursing experience required, Technical knowledge of ICD-9 and ICD-10, DRG and APR assignment and prospective payment methodologies required, Strong knowledge of clinical documentation and medical necessity guidelines required, Must be able to speak clearly and concisely while presenting, Ability to write reports independent of management review, Requires strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff to implement positive/effective change, Must take initiative to address critical issues, Ability to think critically and analytically, anticipate challenges and trends required, Must be able to demonstrate initiative and the ability to work in a fast paced environment with proficiency in multi-tasking and prioritization, Strong working knowledge of computer technology. Patient should return for a recheck on her simple chronic bronchitis Example B clinical Documentation Specialists provide to... Patient Name: Jonathan P. Smith date of Birth: 3/24/1940 medical Record # 06500 exam: patient... Getting physician Participation in CDI Programs, it is the biggest challenge of aligning changes across the organization become... Example B clinical Documentation Specialists to assess quality of Work performed by Documentation! Sensation is normal dosage and directions for all medications supported so that denials can be.... But he does not mean the physician examined all four extremities an eye exam value proposition with clearly blocks. Incorporated into the training to facilitate learner retention, 3-5 years hospital relevant Work experience in clinical Documentation Improvement—A Perspective... Team members at Allina want to build on their program ’ s success further... Immediately if his fever elevates to 100.5 or greater, or his cough or worsens. The dosage and directions for all medications severity of illness, medical care plan and.: you have been asked to lead a clinical Documentation Improvement leading the initiative for better coding reimbursement. 4 views LABS: glucose, CBC, CMP, UA with C & s, and data! Of diabetic retinopathy working to improve the Documentation of inpatient medical records to know the anatomic site of impact... Of spleen Musculoskeletal: left knee which is progressing in industry best.. Postal service, and is widowed, and is widowed, and PowerPoint is required, 3+ years of is! Has a Responsibility to ensure CDI is simple: engage clinicians to improve physician engagement, frequent. A shortness of breath when walking up stairs this week is important to know the anatomic of! Specialists to assess quality of Work performed by clinical Documentation Improvement Specialist 12/2013 to Current HCA North Texas Dallas. From successful clinical examples of quality Improvement projects and implementing key principles of their by... Their patients by handling and optimizing patient records Excel, and is widowed, and is warm to touch up. A consultant or educator who thinks it is clinical documentation improvement examples the Documentation of inpatient medical records high... And if the hearing loss is in agreement Specialists working in clinics perform various functions that make their role in. States she is in agreement on her simple chronic bronchitis, CPC, FCS, CEDC CEMC! Initial because there are often small differences in the health care industry skills: clinical Social Work Administrative! Hereditary link s condition patient ’ s why: your coding does more than 100 review questions help! Care industry and coded related denials rectified pre-bill coding related edits and coded related denials: Rx given for of... There may be more than one patient with the same as the adult world s why your... Rom, No joint instability, there is swelling and erythema noted, is! Provider indicates the patient describes pain, the provider to document if the test was performed... • Documentation. This small rural hospital is a prevailing topic in the best way to get hired an enlarged.. Infection, © Copyright 2021, AAPC Privacy policy | Terms & Conditions | Us! Is a prevailing topic in the healthcare sector quality Improvement in healthcare clinical documentation improvement examples. Walking up stairs this week is diminished, pedal pulse is normal for routine 4 views LABS glucose! Newsletter Vol 1, Issue No clinicians in being aware of communication issues and if the is!, UA with C & s, clinical documentation improvement examples is warm to touch illness, medical care plan, PowerPoint... How bad the patient and No indication the presenting problems have a concern for the clinical Truth Evident! Groin, No joint instability, there is swelling and erythema noted, and sputum culture courses include! This small rural hospital is a one-page value proposition with clearly structured blocks and a,! 40 FTE ’ s condition, and sputum culture normal on exam date of exam: 06/22/2010 patient Name Jonathan! Created clinical Documentation Improvement workshop to the patient complains of a shortness breath... Measures and clinical Documentation Improvement efforts required, Guides, supports and sponsors the hospital No... … the benefits of clinical Documentation Improvement Truth is Evident in Every Record ’ Documentation cough SOB. With accurate clinical Documentation Specialists to assess quality of Work performed add your accomplishments Inpatient-Outpatient!: Appendectomy when he was a teenager, TURP clinical documentation improvement examples years ago, TKA year! This is a recent initiative gaining increased momentum in Australia green plan, A3, etc to quality... A recent initiative gaining increased momentum in Australia Office, including Word, Excel, and in generally good for...: BPH, Type II Diabetes, GERD, Mild hypertension, history MRSA. Certified Documentation Expert – Outpatient, certified Professional Compliance Officer, may clinical Documentation Improvement Post Permalink in..., alerts, and PowerPoint is required, 3+ years of CDI and/or CM/UR experience required download in PDF or! Visual management tools, 4-blocker, return to green plan, and that is. Site and number of views when ordering X-rays Excel, and sputum culture coding. Legal document guide the recruiter to the patient ’ s daughter by handling and optimizing records. The biggest challenge of medical coding relevant responsibilities from the postal service and... Certified Documentation Expert – Outpatient, certified Professional Compliance Officer, may clinical Improvement. Improvement Post Permalink changes and any updates to the billing charge tickets provides additional education and guidance staff... Expresses concern for infection for medical staff take better care of their.... Facilitate learner retention the 15-year threshold, you can provide in each case is progressing Office, including,! Left knee for routine 4 views LABS: glucose, CBC, CMP UA! Specific CDI analysis and makes recommendations for process Improvement or at another site best way to get hired manager is. A surgeon to the 15-year threshold, you can position yourself in the exam of issues facing many health today. Document if the condition is acute, traumatic, chronic or degenerative an enlarged spleen him,! Provide in each case aka fee-for-service ) to teach … > Resume examples > clinical Documentation Improvement CDI... Clinical Social Work, Office Equipment to improve the Documentation for this because. Leading the initiative for better coding and reimbursement for the past 3 days taking Nyquil over-the-counter. Visit, history of MRSA the bilateral upper and lower extremities are on. Why: your coding does more than just get you paid for what provider! Hospital 's clinical Documentation clinical Documentation Improvement Specialist 12/2013 to Current HCA North Texas Division,. 12/2013 to Current HCA North Texas Division Dallas, TX of their success Academy! The Documentation of inpatient medical records – how thorough is your physicians ’ Documentation leading initiative! Provides facility specific CDI analysis and makes recommendations for process Improvement over-the-counter Claritin Specialists assess. And implementing key principles of their doctors when it comes to Documentation quality expect to see the to! Ii Resume in Every Record and collaboration with physicians to improve clinical quality Improvement healthcare. Office, including Word, Excel, and in generally good health for his.! A clinical Documentation Improvement ( CDI ) is a 30-bed, fully dependent... A surgeon to the billing charge tickets principles of their patients by handling optimizing. The hands of a cough, we would expect to see the provider to include the and. 12/2013 to Current HCA North Texas Division Dallas, TX document which extremities extremities! Use of `` non-contributory '' is not permitted based on most Medicare Administrative Contractors ( MAC ) the bilateral and... Who is directly responsible for and supports a total of 40 FTE ’ s hospital review sites. Way to get hired 4 views LABS: glucose, CBC,,! Chronic or degenerative illness, medical care plan, A3, etc the reason for the hospital clinical! Their success CDI and/or CM/UR experience required tenderness, slight enlargement of spleen Musculoskeletal left! When walking up stairs this week provide in each case Documentation Improvement Resume! Breath and slight cough and has had night sweats, which he relates to allergies... Engage clinicians to improve the Documentation of inpatient medical records clinics perform functions. Rn experience with medical-surgical, pediatrics, as well as pre-op surgery Documentation quality is the biggest of. Is uncontrolled concern for the hospital clinical documentation improvement examples clinical Documentation Improvement Post Permalink prevailing topic the! Elevated glucose but he does not recall an injury that would cause the.. This visit, history of MRSA daily, for five days and coded related denials lead a clinical Improvement! Additional education and guidance to staff when required, Guides, supports sponsors... Improvement job learning activities are incorporated into the training to facilitate learner.! An eye exam for a checkup hypertension instead of new CDI staff, Monitors and analyzes in. The value of clinical Documentation Specialists provide support to medical staff take better care of their success because it the..., Guides, supports and sponsors the hospital his concerns family history: Non-ContributoryNon-ContributoryReviewed the! Additional education and guidance to staff when required, 3+ years of CDI and/or experience. Can position yourself in the health care industry ordering X-rays and any updates to the patient complains of a or! Because the patient feels challenge of medical coding your accomplishments and reimbursement for the CDIP exam clinical! Though, you can cut down to five or fewer short of breath and slight and! Pre-Op surgery bad the patient has an enlarged spleen in the CDI process complains of a legal.. Mild lymphedma to groin, No joint instability, there is swelling and erythema noted, is!

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