I have a clinical background and want to become a CDS; do I need a coding qualification?

Nour Alatari May 20, 2024
In the intricate world of healthcare, Clinical Documentation Specialists (CDSs) play a vital role in ensuring patient records are accurate and..

CDI Strength: Beat Risks, Boost Sustainability

Mike Kertes March 27, 2024
In the ever-evolving landscape of healthcare, Clinical Documentation Improvement (CDI) stands out as a critical pillar, ensuring the accuracy,..

CDI Queries Work Best if the Recipient is Kept in Mind

Dr Erica Remer March 13, 2024
I had an epiphany the other day while discussing compliant query composition with a very knowledgeable clinical documentation integrity specialist..

A CDI Year-In-Review

Mike Kertes December 7, 2023
Reflecting on the past year in the realm of Clinical Documentation Improvement (CDI), particularly in countries using ICD-10-AM and AR-DRGs, it's..

Reflecting on CDI 2023 - Harnessing Momentum: A Turning Point for Clinical Documentation Improvement (CDI)

Mike Kertes September 19, 2023
As I sat on the plane on my return flight home from the Gold Coast, I couldn't help but feel a sense of pride and elation to be a part of something..

Clinical Documentation Improvement- a nursing role?

Joanna Forteath July 31, 2023
This article was first published in the Australian Nursing & Midwifery Journal (ANMJ) Jul-Sep Volume 28, No. 1 and has reproduced with consent. If I..

'What the Heck is This?' Written Documentation Queries: A Clinician's Perspective

Dr Felicity Sinclair-Ford May 26, 2023
What do we want? Clinicians who document efficiently and thoroughly, specifying diagnoses, linking them to interventions, and including pertinent..

A Week Back on the Wards

Dr Felicity Sinclair-Ford January 19, 2023
Dr Felicity Sinclair-Ford reflects on her recent time working clinically and how it illustrates potential challenges with clinician engagement.

A Tale as Old as Time: Heart Failure & Fluid Overload Part 2

Dr Felicity Sinclair-Ford December 13, 2022
In the last instalment, Dr Felicity Sinclair-Ford went on a quest to find all the coding standards and advice relevant to heart failure and fluid..

"Due To" Methylene Blue: A CDS Goes Down the Rabbit Hole

Cheryl Fenwick Evans December 2, 2022
Working as a CDS in the cardiovascular department, Cheryl Fenwick Evans saw a diagnosis she wasn't familiar with. Determined to know more, she dug a..

A Tale as Old as Time: Heart Failure & Fluid Overload

Dr Felicity Sinclair-Ford November 28, 2022
In a daring (yet pedantic) exploration, Dr Felicity Sinclair-Ford wants to dig deep into the coding rules around heart failure and fluid overload.

CDI: Documenting Diagnoses and Patient Safety

Cheryl Ericson July 29, 2022
Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient..

What does clinical engagement look like in practice?

Qun Catherine Li July 19, 2022
The term of clinical engagement came to me very early in my safety and quality (S&Q) endeavour, my very first S&Q role almost 11 years ago. Two..

Our New Healthcare Heroes: The Next Generation of Clinical Documenters

Dr Felicity Sinclair-Ford February 11, 2022
It’s a frenetic time in Australian hospitals. After two years of COVID-19 suppression strategies, our borders, our country, and our lives, have..

The Clinical Documentation Process has Become Longer, More Repetitive, and Less Informative

Dr Erica Remer December 3, 2021
This insightful article from America shows that problems with clinicians using the "copy and paste" function in electronic medical records are not..