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CDI: Documenting Diagnoses and Patient Safety

Cheryl Ericson July 29, 2022
Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient..

How to work with clinicians for better data

Dr Felicity Sinclair-Ford August 18, 2021
Working with doctors and developing relationships doesn’t just get buy-in from clinicians – it ensures data is accurate.Nicole Draper is CDIA’s..

Why “we need to get the coding right” is the wrong message

Dr David Tralaggan August 6, 2021
Blaming your problems on clinical coding ignores the real culprit – your clinical documentation. “We need to get the coding right!” is a comment we..

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..

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..

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..