Posts about
coding
Beyond Nursing Checklists
April 3, 2025
Beyond Nursing Checklists: Why Comprehensive Nursing Documentation Matters In modern healthcare, nursing documentation is a fundamental aspect of..
Remote CDI- Is It Really Effective?
March 7, 2025
Onsite Clinical Documentation Improvement (CDI) programs are designed to enhance the accuracy, completeness, and specificity of medical..
CDI: It's Not About Who
January 28, 2025
At a recent conference, I was exposed to several thought-provoking conversations about who should ‘own’ clinical documentation improvement (CDI). Who..
Securing the Future: The Imperative of CDI in Healthcare
June 14, 2024
Australia's private and public health systems are currently facing immense pressures that threaten their sustainability. These pressures, driven by..
I have a clinical background and want to become a CDS; do I need a coding qualification?
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
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
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
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)
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?
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
May 26, 2023
What do we want? Clinicians who document efficiently and thoroughly, specifying diagnoses, linking them to interventions, and including pertinent..
A Tale as Old as Time: Heart Failure & Fluid Overload Part 2
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
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..
CDI News USA: Texas hospital to pay $3 million in whistleblower case
September 10, 2021
A case from America illustrates the serious consequences of upcoding.