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The key players on a CDI team are clinicians, clinical documentation specialists (CDS), and inpatient coders. ... The clinical documentation specialist's role is, through medical record review, to capture pertinent clinician documentation while the
They added that their research makes progress toward ACP's recommendations to improve note accuracy and develop automated tools that enhance documentation quality. ... Institutions should consider developing internal best practices for clinical
Numerous clinical and non-clinical consequences of documenting the diagnoses of acute and chronic respiratory failure. ... Our Clinical Documentation Improvement (CDI) program has struggled with the clinical definition of acute renal failure because we
patients with latent tuberculosis, a new study indicates. Researchers at 12 outpatient tuberculosis clinics performed an open-label, phase 4 randomized clinical trial to compare rates of treatment completion and safety ... Clinical documentation and pill
Although Dr. Skandhan, who is now medical director/physician liaison for clinical documentation improvement, had no specific training in documentation, he worked with a colleague to look for resources and create ... teaching modules for the group as part
Preoperative heart failure was based on clinical documentation, and postoperative heart failure (including exacerbations) was based on Framingham criteria.
The rules that govern code assignment for pneumonia bear little relationship to long-accepted clinical documentation practices. ... The rules that govern code assignment bear little relationship to long-accepted clinical documentation practices for
on the best way to use copy-and-paste in your clinical documentation system.
In clinical coverage, our feature examines allergic reactions in the hospital, which in adults most often occur as a result of drug reactions. ... Meanwhile, our Test Yourself section on will help you bone up on hematology, while our coding column
According to the Medicare Benefit Policy Manual, the medical record must include documentation that the physician explicitly assessed patient risk to determine that the patient would benefit from observation care. ... For the past 24 years, she has