How to have productive clinical discussions
July 5, 2021
Clinical documentation improvement (CDI) is about having effective clinical discussions that change behaviours – it is NOT about telling doctors what..
CDS - Scope Creep
June 17, 2021
Are people in your hospital asking you to work beyond the scope of your clinical documentation specialist (CDS) role? You may be experiencing scope..
What Is a Leading Query?
June 14, 2021
It is disheartening that there are still misconceptions about what a leading query is. In my last article, “The Query Conundrum,” I briefly talked..
Junior doctors: paperwork lackeys or key allies for CDI? Part 2
June 4, 2021
Junior doctors occupy a unique and sometimes strange position within the hospital. We are doctors. We’re called when people are sick and..
Junior doctors: paperwork lackeys or key allies for CDI?
May 20, 2021
It’s 6:30am on the general surgical ward. Three residents are preparing for the round. We’re looking up results, printing lists, and creating ward..
The Query Conundrum
May 3, 2021
To query or not query that is the question. Querying is the lifeline of clinical documentation integrity (CDI) professionals and many coding..
CDI is a journey, not an event
May 3, 2021
If you think your hospital has “done” clinical documentation improvement (CDI), it may be time to think again. Improving your clinical documentation..
Who makes the best Clinical Documentation Specialist?
April 20, 2021
The CDS is the most important element in any clinical documentation improvement (CDI) program. CDI is a behavioural change process implementing..
The symbiotic relationship between your HIM and CDS teams
April 5, 2021
Strong cohesive relationships will significantly enhance the success of your clinical documentation improvement (CDI) program. Henry Ford's famous..