What is the CDI process?
CDI (Clinical Documentation Improvement) has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. Clinically, it results in a more useful medical record and more meaningful patient information and data.
What is a clinical documentation nurse?
A CDS is a registered nurse who manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation.
What is CCDS Certification?
The Certified Clinical Documentation Specialist (CCDS) examination is designed to test an applicant’s ability to recall documentation and coding guidelines and industry regulations pertaining to clinical documentation improvement and apply that knowledge to real-life scenarios clinical documentation specialists face …
What is CDI healthcare?
Clinical documentation improvement (CDI) helps ensure that the events of the patient encounter are captured accurately and the electronic health record properly reflects the services that were provided.
Is CDI always treated?
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What is the goal of the clinical documentation improvement CDI compliance review?
The goal of these reviews is to identify clinical indicators to ensure that the diagnoses and procedures are supported by ICD-9-CM codes. The method of clarification used by the CDI professional is often written queries in the health record.
What is outpatient CDI?
1. Some organizations define outpatient CDI as all hospital-based services outside the inpatient setting. Other organizations may limit outpatient CDI to documentation and coding in physician practices and clinics.
How do I start an outpatient CDI program?
Ten Steps to Create a Successful Outpatient CDI Program
- Gather data and assess the current state.
- Define program scope and approach.
- Outline program goals and ongoing data needs.
- Determine return on investment.
- Develop program staffing infrastructure.
- Define initial workflow and processes.
- Communicate and educate.
- Set performance expectations.
What is CD in nursing?
CDS = clinical decision support; SD = standard deviation. Table 3 describes the characteristics of nurses in the use and non-use groups.
What is a CDI Professional?
CDI professionals act as intermediaries between Inpatient coders who translate diagnoses into data and healthcare providers and nurses. …
What does CDI mean in healthcare?
Clinical documentation improvement
Why are vision statements important to CDI programs?
The “vision” of the CDI program should reflect the facility’s goals and desires, including accurate DRG assignment, quality monitoring, and optimal reimbursement.
What is a CDI vision statement?
2011-2018 CDI’s Vision, Mission, Values, and Goals We act to ensure vibrant markets where insurers keep their promises and the health and economic security of individuals, families, and businesses are protected.