Posts about

Clinical Documentation Specialist

I'm a CDS, Now What? - Transitioning into the CDS Role

Samantha Ryan October 25, 2021
Experienced Clinical Documentation Nurse Consultant Samantha Ryan reflects on the leap from clinical nurse to CDS.

CDS - Scope Creep

Dr David Tralaggan 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?

Cheryl Ericson 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

Dr Felicity Sinclair-Ford 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?

Dr Felicity Sinclair-Ford 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

Cheryl Ericson 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

Dr David Tralaggan 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?

Mike Kertes 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

Mike Kertes April 5, 2021
Strong cohesive relationships will significantly enhance the success of your clinical documentation improvement (CDI) program. Henry Ford's famous..

The science behind clinical documentation improvement (CDI)

Dr David Tralaggan February 23, 2021
Discover why clinical documentation improvement is a behavioural change process that requires a scientific approach. If you’re thinking about..

What does a Clinical Documentation Specialist (CDS) do?

Nicole Draper February 10, 2021
Learn about the essential daily tasks of a CDS. You may have seen CDS roles advertised within your hospital or online, and you’re wondering what the..

Establishing a CDI steering committee

Nicole Draper January 7, 2021
Discover why a steering committee is a vital piece in your approach towards clinical documentation improvement. What is a steering committee? A..

Bridging the gap between HIM coding and CDI professionals

Steven Robinson MS, PA, RN, CDIP April 26, 2017
Unity is strength… when there is teamwork and collaboration, wonderful things can be achieved. — Mattie Stepanek Clinical documentation..