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

I had an epiphany the other day while discussing compliant query composition with a very knowledgeable clinical documentation integrity specialist..

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..

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..

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 do we want? Clinicians who document efficiently and thoroughly, specifying diagnoses, linking them to interventions, and including pertinent..

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..

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 case from America illustrates the serious consequences of upcoding.