CDI best practices: Capturing the true clinical story
advertisement
Current Location:
>
> This Story


Log in or Register to rate this News Story
Forward Printable StoryPrint Comment
advertisement

 

advertisement

 

Health IT Homepage

Data sharing 'insufficient' for close to a third of healthcare providers Survey finds many switching to single, integrated EHRs to be interoperable

PHDA and Amazon Web Services team up in machine learning healthcare sponsorship Aiming to enhance medical imaging, precision medicine and cancer diagnostics

Actively regulated EHR standards are driving demand for outsourcing critical functionality Staying ahead of the curve as SCRIPT17 deadline approaches

Patient record breaches in 2019 already double the total from last year Report finds almost 32 million patient record breaches, compared to 15 million in 2018

Kaiser Permanente team standardizes definition of complete imaging history Developed prompts to help in order entry process

Everyone’s part in the perfect EMR Tips for optimizing your facility's approach to patient data

Getting physicians to embrace telehealth By 2025 the U.S. telemedicine market is expected to exceed $64 billion

Browser beware: Study uncovers data leaks that could impact health IT Chrome and Firefox extensions may cause vulnerability

Carestream completes sale of IT business to Philips in most countries Now part of Philips in 26 of 38 countries where it operates

The building block(chain) of healthcare’s future? Insights from Eliot Siegel on what needs to happen for blockchain to improve the industry

CDI best practices: Capturing the true clinical story

• When there are clinical indicators of a diagnosis but there is not documentation of a condition to coincide with those indicators
• There is clinical evidence for a higher degree of specificity or severity of an illness
• There is uncertainty of a cause-and-effect relationship between two conditions or organisms
• When clarification is needed for an underlying cause of symptoms
Story Continues Below Advertisement

THE (LEADER) IN MEDICAL IMAGING TECHNOLOGY SINCE 1982. SALES-SERVICE-REPAIR

Special-Pricing Available on Medical Displays, Patient Monitors, Recorders, Printers, Media, Ultrasound Machines, and Cameras.This includes Top Brands such as SONY, BARCO, NDS, NEC, LG, EDAN, EIZO, ELO, FSN, PANASONIC, MITSUBISHI, OLYMPUS, & WIDE.



• Treatment is documented without a corresponding diagnosis
• Clarification if a condition was present on admission (POA)
• A diagnosis is documented without any clinical indications in the patient record
• There may be instances where a query is needed due to lack of completeness, inconsistent documentation or clarification is needed

Queries as noted above may be presented as verbal, written, or electronic. Best practices for the information contained within the query include: stating clearly and concisely why the query is being presented; the clinical indicators, medical evidence, or supporting data present in the health record which prompted the query; and the named CDI professional presenting the query. The impact on reimbursement or quality measures should not be included in the query.

Implement a clinical validation process
Clinical validation is a growing segment of CDI practices. There may be occasion when a diagnosis documented within the health record does not appear to be supported by the clinical evidence within the health record. This is where the clinical validation query comes into play. The updated AHIMA practice brief, “Clinical Validation: The Next Level of CDI”, which will also be addressed at AHIMA’s CDI Summit in July, explains that the clinical validation query is to “identify potential gaps in the clinical picture and send queries to clarify.” The provider is responsible for the establishment of all diagnoses and may be queried when there are gaps between the clinical evidence in the health record and documented diagnoses.

Create clear written policies and procedures
It is crucial for an organization to develop policies and procedures for all CDI related processes. Policies and procedures clearly outline the duties, processes and expectations of CDI activities and those departments and individuals involved. This ensures standardization and defines the roles and responsibilities as well as organization specific policies. Examples of policies and procedures include:
• CDI onboarding: This should include all CDI practices, workflow and expectations
<< Pages: 1 - 2 - 3 >>

Health IT Homepage


You Must Be Logged In To Post A Comment