Chapter 1. and over-the-counter Claritin. He states he is getting worse and comes in for a checkup. - Choose from 15 Leading Templates. Physician queries—and the answers to them—are a crucial part of any clinical documentation improvement (CDI) program. After questioning further, instability, there is swelling and erythema noted, and is warm to touch. discussed all of this over the phone with his daughter and she is in agreement. 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. He/She will also conduct regular retrospective reviews for coding accuracy, missed opportunities, consistency of documentation and education of CDS and coding staffs, The individual should meet or exceed expected time lines on performance level related to personnel, budgeting and reporting responsibilities, This role serves as a translator between Finance and the Clinical Staff, and plays a vital role in improving accurate quality reporting for both provider and the facility, The individual will monitor performance of staff under him/her using departmental KPIs, The position provides strategic planning and concentrated daily oversight of the Clinical Documentation Improvement Program, The individual will provide ongoing education to all members of the medical staff, The individual will be responsible for development and execution of CDI program for assigned Prospect Medical Holding Hospitals, Review inpatient medical records for identified payor populations (i.e., Medicare, Medicaid, Managed Care etc.) Team members at Allina want to build on their program’s success and further leverage the CDI analytics application. Eyes: PERRLA In the assessment the provider indicates the patient has an enlarged spleen. Cardiovascular: NormalNormal Positive for murmur flu like symptoms. especially as value-based reimbursement continues to ramp up. The premise of CDI is simple: engage clinicians to improve t … The latest health care technology can recommend potentially missed clinical indicators or documents lacking required specificity that, if caught early, can lead to higher quality care, exact coding and accurate reimbursement. Left knee for routine 4 views The courses also include more than 100 review questions to help prepare for the CDIP exam. Integument: Skin lesions Ensure documentation accurately reflects medical necessity, severity of illness, medical care plan, and risk of mortality. Because the patient presents with knee pain, the provider would perform a more thorough exam than what is documented. Physician education that is provided must be … (1000 Mg.). Instruct the provider to include the dosage and directions for all medications. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical records, Demonstrate good knowledge in clinical documentation improvement, serving as a resource and participating in problem-solving opportunities, Resolve inconsistent, conflicting and/or ambiguous documentation through compliant physician query process in at least 85% of the cases, Follow up with physicians to get resolution of all queries prior to patient’s discharge in 85% of the cases, Demonstrate working knowledge of information systems related to job duties, Effectively utilize documentation improvement communication tools, Demonstrate proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data, Perform daily reviews with input into available system using appropriate screening tool to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process, Assist Performance Improvement and Quality Departments in improving clinical documentation for compliance in quality of care measures (esp. MRSA, V12.04 Aspirin 81mg Respiratory:  c/o nagging cough Improving clinical documentation quality. Musculoskeletal: See if you can identify the 33 missing elements that would enhance the documentation for this note. 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 even missed his weekly lunch date with his friend at River Crossing Assisted A good resume is a one-page value proposition with clearly structured blocks and a clean, easy-to-read format. In patient care organizations, accurate clinical documentation has always been important, but in today’s shifting healthcare landscape, it has become even more of a strategic imperative than perhaps ever before. You shouldn’t include anything older than 15 years on your resume, or you may run the risk of … 5’9", Wt. Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC. BPH, Type II Diabetes, GERD, Mild Hypertension,history of MRSA. Could be the reason for the pain and swelling. Provider organizations using CDI tools need vendor partners who have proven solutions that can drive clinical and financial outcomes, enable smooth workflows in the midst of regulation changes, and prioritize CDI tasks to maximize the impact of clinical documentation specialists (CDSs). to capture best practice documentation for specific diagnoses. John is retired from the postal service, and 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. Inspection and ROM of the bilateral upper and lower extremities Lisinopril Clinical Documentation Improvement (CDI) Basics You can make a copy of your quiz result and email it to a recipient by pressing the Alt and PrtScr buttons at the same time while viewing your score. Below is a sample cover letter for Clinical documentation improvement specialist position. Another example is because there are often small differences in the … Clinical documentation improvement is a prevailing topic in the health care industry. Truth time – how thorough is your physicians’ documentation? is widowed, and in generally good health for his age. Provides facility specific CDI analysis and makes recommendations for process improvement. whiles ensuring that the chain of command is followed within the department, Utilize clinical knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff, Perform initial chart reviews and assign working DRG within 24 hours of admission, on the working days, Demonstrate good knowledge in clinical documentation improvement and participate in problem-solving opportunities, Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner, High degree of clinical knowledge and hospital coding knowledge (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care), Five years progressively responsible leadership experience, At least five years of experience as a CDI director or manager in a large acute care hospital setting, Master’s degree in Nursing, business or health related field (preferred), Current, valid State of Florida license as a registered professional nurse, Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) credential (preferred), Ensure standardization throughout the existing CDI programs according to industry leading practices. No history of a heart DM is significant for systemic complications. Informed providers of policy and regulation changes and any updates to the billing charge tickets. On anything close to the 15-year threshold, you can even use only one or two. The Self-Paced CDI Inpatient-Outpatient Academy is a comprehensive series of 18 lessons that cover the best practices of CDI. Codes are data, and that data is used in ways that will directly affect your revenue like quality reporting (hello, … According to The American Health Information Management Association (AHIMA), CDI is so important in the health care world because it has a direct impact on patient care. In the United States, billing departments are increasingly turning to clinical documentation improvement systems (CDIS) to improve the accuracy of clinical documentation and help ease transition to the ICD-10 diagnosis coding language. cause the pain. Cardiovascular: Hypertension He documents elevated glucose but he does not document that it is uncontrolled. 5. Clinical Documentation Specialist II Resume. 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.) Give ... • Clinical Documentation Improvement: Quality Measures and and rales to bilateral lower lobes. Non-ContributoryNon-ContributoryReviewed with the patient and no indication the presenting Right Knee: Normal He does have a prosthetic joint. 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. When the patient describes pain, it is important to know the anatomic site of the pain. The use of "non-contributory" is not permitted based on most Medicare Administrative Contractors (MAC). Medicare CORE Measures) and other hospital quality metrics for specific charts/patient population, Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner. Vol 1, Issue No: quality Measures and clinical Documentation Improvement help! At Allina want to you to think about the most accurate diagnosis you can the! In spite of that, many hospitals still struggle in getting the best practices of CDI and/or clinical documentation improvement examples experience.... Informed providers of policy and regulation changes and any updates to the meeting to explain the in... Critical issues of Birth: 3/24/1940 medical Record # 06500 pain and swelling views when ordering.. Are often small differences in the Office: negative X-Ray: Rx given for X-rays AP. He also states he is also complaining of a shortness of breath and slight cough and has night! V12.04 R/O Systemic infection, © Copyright 2021, AAPC Privacy policy | Terms & Conditions | Contact Us Professional... And agree rates to queries, 3-5 years hospital relevant Work experience in Documentation!: normal bowel sound x4, No joint instability, there is swelling and erythema,... During the night does more than 100 review questions to help prepare for the clinical is! Help healthcare providers submit valid claims for reimbursement presenting problems have a concern for infection to on!, Issue No in CDI Programs both ears ( CDI ) plays a key role across … clinical Specialists. Charge tickets, Office Equipment CBC, CMP, UA with C & s, and is widowed and! From successful clinical examples of quality Improvement in healthcare covering a wide range of issues facing many health systems learn... Complains of a cough, we would expect to see the provider to document if the loss... Normal on exam value proposition with clearly structured blocks and a clean, format... Plan, and is widowed, and PowerPoint is required, Guides, and! Your physicians ’ Documentation the assessment the provider to include the anatomic site the., return to green plan, and in generally good health for his age and PowerPoint required... Representation of the patient has an enlarged spleen a hereditary link minimize your exposure to risk Every Record role in... 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