Electronic Health Records

Clinical Documentation Improvement

AHIMA Fuels Clinical Documentation Improvement with New Toolkits

May 7, 2018 - Clinical documentation improvement (CDI) helps healthcare organizations capture meaningful data for improved quality reporting and clinician productivity. In an effort to ensure that the entire patient record is documented properly, AHIMA released two new CDI toolkits earlier this month to ensure data exchange is accurate and complete. The two new toolkits focus on CDI on outpatient documentation...

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Epic Clinical Documentation Module Utilizes AI Solution

by Kate Monica

Epic’s clinical documentation improvement (CDI) module NoteReader will now utilize artificial intelligence (AI) solutions for automated physician feedback. M*Model and its embedded M*Modal Computer-Assisted Physician Documentation (CAPD)...

Realizing the Benefits of Clinical Documentation Improvement

by Kate Monica

Physician practices and healthcare organizations have been batting around the idea of clinical documentation improvement (CDI) for over ten years. The American Health Information Management Association (AHIMA) has taken a particular interest...

Can Natural Language Processing Boost Clinical Documentation?

by Sara Heath

Numerous reports pointed to EHR use as a contributor to increased physician workloads, specifically citing the time demands of clinical documentation processes. According to a recent study, dictation and natural language processing (NLP) may...

WEDI Clarifies Clinical Documentation in 2017 ICD-10 Guidance

by Sara Heath

The Workgroup for Electronic Data Interchange (WEDI) has released an issue brief on clinical documentation and the 2017 ICD-10 Official Guidelines. The 2017 guidelines include a specific provision about clinical documentation. In guideline 19,...

Does Speech Recognition Aid Clinical Documentation Improvement?

by Kyle Murphy, PhD

Despite the availability of speech recognition software and natural language processing over the past two decades, research shows limited evidence proving these technologies to have a clearly positive impact on clinical documentation improvement....

Leveraging Health IT for Clinical Documentation Improvement

by Kyle Murphy, PhD

Well before the implementation deadline for ICD-10 last October, clinical documentation improvement was a well-established aim of healthcare organizations and providers seeking gains in both clinical efficiency and data integrity. Now with the...

Tips for Approaching Clinical Documentation Improvement

by Sara Heath

Clinical documentation is an important bridge between healthcare coders and physicians. The accurate documentation of health services provided benefits healthcare organizations not only with regard to revenue cycle, but with accurate care delivery...

Efficiency of Remote Clinical Documentation Improvement Work

by Vera Gruessner

Would working remotely on clinical documentation improvement (CDI) improve efficiency at a healthcare organization? Some may not think so, but the results from Baystate Health indicate otherwise. As part of its CDI program, Baystate Health in...

CDI Moves beyond ICD-10 for Revenue Cycle Management Gains

by Jennifer Bresnick

For some savvy organizations, clinical documentation improvement is more than just another onerous piece of the dreaded ICD-10 implementation puzzle.  While the countdown to October 1, 2015 is certainly at the forefront of the healthcare industry’s...

ICD-10 Improvement for Physicians Requires Fast, Simple Tools

by Jennifer Bresnick

Clinical documentation improvement (CDI) for ICD-10 is one of the perpetual pain points tormenting healthcare organizations in the lead-up to October 1, 2015.  Overworked physicians are frustrated by the sheer scope of changes that they are...

Mature CDI Program Helped Prepare Us Early for ICD-10 Switch

by Jennifer Bresnick

Clinical documentation improvement (CDI) is the cornerstone of any successful ICD-10 transition program.  While the ICD-10 delay has given healthcare organizations an extra twelve months to get their providers on board with the increased requirements...

71% of Hospitals Plan to Have CDI Partner for ICD-10 by 2015

by Jennifer Bresnick

Seventy-one percent of hospitals plan to enlist an ICD-10 clinical documentation improvement (CDI) services partner by the third quarter of 2015, according to a new Research and Markets report, to help them meet more stringent documentation requirements...

CDI Specialists Must Creatively Train Physicians for ICD-10

by Jennifer Bresnick

Clinical documentation improvement (CDI) goes far beyond the detail and specificity requirements of ICD-10, but HIM professionals who are scrambling to get their organizations in shape for the big switch on October 1, 2015 have just twelve months...

71% of hospitals plan CDI partnerships to tackle ICD-10

by Jennifer Bresnick

The majority of hospitals won’t be staring down the challenges of ICD-10 clinical documentation improvement (CDI) on their own, Black Book Rankings says, but will seek consultants and service partners to help them make the necessary adjustments...

CDI produces financial, clinical benefits apart from ICD-10

by Jennifer Bresnick

With ICD-10 an ever-present threat on the horizon, clinical documentation improvement (CDI) programs have suddenly become all the rage.  Healthcare organizations caught up in preparations for the new code set, ready to pounce on October 1, 2015,...

Five ways to avoid potential ICD-10 productivity losses

by Jennifer Bresnick

Last week, the American Medical Association released some frightening statistics about the financial impact of ICD-10 that caused quite a flutter among providers.  More than tripling the anticipated costs to healthcare providers, the report...

Have EHRs, CPOE set the stage for ICD-10 acceptance?

by Jennifer Bresnick

There’s never been any shortage of grumbling about the difficulty of adopting EHRs and their companion technologies like computerized physician order entry (CPOE).  Physicians are concerned about productivity, ease of use, the potential...

ICD-10 education, CDI training must be flexible for physicians

by Jennifer Bresnick

In the few months left before ICD-10 collides with the healthcare industry, providers have a last chance to close the gap by providing training and education to their physicians and coders.  Documentation must be improved, coding skills must...

Why ICD-10 Is Not Just A Coding Project

by Sponsored Content

If you think ICD-10 is all about new codes, you are dead wrong. ICD-10 is really about “documentation” ─ we clinicians have learned from day one that, “If it’s not documented, it wasn’t done.” This situation...



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