Clinical Documentation Improvement Principles and Practice (EPUB)

1.1.Description

Clinical Documentation Improvement: Principles and Practice (EPUB) elucidates the pivotal role of clinical documentation as the cornerstone of every patient health record.

The book meticulously defines this foundational term, underscores its paramount importance, and presents a set of objective and uniform principles applicable across diverse healthcare organizations’ clinical documentation improvement (CDI) programs.

The author systematically addresses key stakeholders, ranging from patients and clinicians to coding professionals and reimbursement entities, emphasizing the profound impact of a robust CDI program on all involved parties.

Divided into three parts, the book navigates through the fundamentals of clinical documentation, guiding organizations in assessing and enhancing their current documentation quality. It then delves into the intricacies of CDI program implementation, covering staffing, training, querying physicians, data analysis, and program compliance.

With an eye on growth and refinement, the book’s final section outlines a strategic process for evolving a sustainable clinical documentation program.

Noteworthy features include an exploration of the CDI process’s adaptation to the ICD-10 transition, a new chapter on critical thinking, extensive guidance on program analytics, and practical resources for program implementation and management.

Clinical Documentation Improvement: Principles and Practice (EPUB) serves as an authoritative guide, meticulously elucidating the fundamental significance of clinical documentation within the patient health record framework.

The book rigorously defines the term, establishes its critical importance, and introduces a set of objective and uniform principles applicable across diverse healthcare organizations engaged in clinical documentation improvement (CDI) programs.

Addressing key stakeholders, from patients to clinicians, coding professionals, and reimbursement entities, the author underscores the transformative impact of a robust CDI program.

The book’s three-part structure navigates through fundamental assessment and enhancement of documentation quality, the intricacies of program implementation, and strategic processes for program evolution.

Noteworthy features include insights into the CDI process’s adaptation to the ICD-10 transition, a new chapter on critical thinking, extensive guidance on program analytics, and practical resources for program implementation and management, making it an indispensable resource for healthcare organizations committed to excellence in clinical documentation.

Clinical Documentation Improvement

1.2.Key Features

The key features of Clinical Documentation Improvement: Principles and Practice (EPUB) are as follows:

1. Foundational Understanding: The book provides a clear and comprehensive definition of clinical documentation, emphasizing its foundational role in every patient’s health record.

2. Universal Principles: Clinical Documentation Improvement: Principles and Practice (EPUB) presents a set of objective and uniform principles applicable across various healthcare organizations engaged in clinical documentation improvement (CDI) programs, ensuring a standardized and systematic approach.

3. Stakeholder Focus: The author systematically addresses key stakeholders involved in clinical documentation, including patients, clinicians, coding professionals, and reimbursement entities. The book highlights how a robust CDI program positively affects all these stakeholders.

4. Three-Part Structure: The content is organized into three parts. Part 1 addresses the fundamentals of clinical documentation, Part 2 covers the implementation of CDI programs, and Part 3 focuses on recommendations for growing and refining a clinical documentation program.

5. ICD-10 Transition Considerations: Clinical Documentation Improvement: Principles and Practice (EPUB) expands on how the transition to ICD-10 impacts the CDI process, providing insights and considerations specific to coding scenarios during this transition.

6. New Chapter on Critical Thinking: A new chapter is dedicated to critical thinking for physicians, nurses, clinical documentation specialists, and coders, enhancing their ability to contribute effectively to the CDI process.

7. Guidance on Program Analytics: Clinical Documentation Improvement: Principles and Practice (EPUB) offers extensive guidance on CDI program analytics, emphasizing their importance for sustainability. This includes insights into the latest CDI technology solutions, an example query set, and work plans for program implementation.

8. Practical Resources: Practical resources are provided, including an example presentation on physician education and engagement, as well as strategies for APR-DRG CDI programs and denials management.

In summary, Clinical Documentation Improvement: Principles and Practice (EPUB) stands out for its comprehensive coverage, stakeholder-focused approach, consideration of the ICD-10 transition, inclusion of critical thinking insights, practical resources, and emphasis on program analytics. These features make it a valuable guide for healthcare organizations aiming to enhance the quality of their clinical documentation.

Clinical Documentation Improvement

Summary

Clinical Documentation Improvement: Principles and Practice (EPUB) serves as a comprehensive guide, meticulously detailing the fundamental role of clinical documentation within patient health records.

Authored with precision, the book defines clinical documentation and underscores its critical significance, presenting a set of objective and uniform principles applicable to diverse healthcare organizations engaged in clinical documentation improvement (CDI) programs.

Addressing key stakeholders from patients to clinicians, coding professionals, and reimbursement entities, the book navigates through three parts, covering the fundamentals of clinical documentation, CDI program implementation, and recommendations for program growth.

Noteworthy features include insights into the CDI process’s adaptation to the ICD-10 transition, a new chapter on critical thinking, extensive guidance on program analytics, and practical resources for program implementation and management.

This resource stands as an invaluable tool for healthcare organizations committed to elevating the quality of clinical documentation.