What's Your Position on the Primary Purpose of Clinical Documentation?

Effective physician communication of patient care serves a wide array of different purposes in the overall scheme of healthcare delivery, the most important consisting of facilitating fully informed...

Physician encounters should be long-term relationships, not one-night stands

Excellent read  (link at conclusion of blog) about the misconceptions of Emergency Department care as primary episodic care, significant inroads are being made to integrate ED care with primary...

Hospital Readmission Without Septicemia

Palmetto GBA just this week posted on its website an article titled Hospital Readmission Without Septicema discussing the CMS Hospital Readmission Reduction Program. pointing out the cost of unplanned readmissions is $15 to $20 bi...

Effective Clinical Documentation Integrity Processes

Mechanics of Chart Review Process

Any clinical documentation integrity initiative must embrace the concept of proactivity versus reactivity, rejecting the reactive tendency of complacency and content. Proactivity facil...

A Real Story

I recently talked with a colleague on the phone who has been out of work for over a year now, this despite the fact the economy is performing well on all major indices. Now, granted my colleague has her age going against her as a strong headwind, she has be...

Take Stock in Your CDI Program-Check Under the Hood

Complacency is the main contributing factor that leads to suboptimal performance and achievement of sustainable operational processes and outcomes for any business. Clinical documentation improvement programs have disc...

Clinical documentation improvement spans the entire continuum of care from the time the patient presents to the Emergency Department or is direct admitted to the hospital until the time of patient discharge and the completion of the discharge summary. The CDI specialis...