Clinical Documentation Improvement (CDI)
Clinical Documentation Standardization Reduction in Claims Denials and Improved Coder Productivity Increased Quality Measures for Providers
In many hospitals today, care is still documented utilizing individual unit or clinician specific methods and preferences.
A range of terminology may be used to describe the care and new forms proliferate, creating redundancies, making trending and quality reporting difficult,
impeding smooth data flow into the EMR, and ultimately defeating the integrated capabilities of today’s leading advanced
clinical systems. This lack of standardization can be the case whether the health record is hardcopy or electronic.
The implementation of advanced clinical systems and electronic medical records provides the best opportunity to standardize documentation and
implement care planning models that utilize standardized language. This effort is vitally important to meet the intent of Meaningful Use criteria and to
provide more effective and satisfactory use of the electronic health record.
We provide expert Clinical Specialists who assist health care facilities to:
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