Posts about
Data Integrity
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..
Copy & Paste - Foe or Ally
October 21, 2024
The electronic health record can be the physician’s foe or opponent, depending upon how the record is used and the information charted. The benefits..
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 Week Back on the Wards
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
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..