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Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
AHIMA describes its foundation as a sister organization to the Association for Healthcare Documentation Integrity (AHDI) and states the foundation has a charitable and educational nature. The foundation formulates and issues opinions, supports education, conducts research and compiles its contributions into the AHIMA BoK (body of knowledge).
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
Electronic documentation of patient visits and data could open physicians to an increased incidence of malpractice suits. Disabling physician alerts, selecting from dropdown menus, and using templates can encourage physicians to skip a complete review of past patient history and medications and thus miss important data.
AHIMA also offers a registered health information technician (RHIT) certification for coding professionals with two-year associate degrees and with less emphasis on management responsibilities. In 2005 researchers found that the differences in these certifications, in addition to other accreditations offered by AHIMA and the need for ongoing ...
A Certified Healthcare Documentation Specialist (CHDS) credential can be earned by passing a certification examination conducted solely by the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), as the credentialing designation they created. AHDI also offers the ...
In qualitative research, a member check, also known as informant feedback or respondent validation, is a technique used by researchers to help improve the accuracy, credibility, validity, and transferability (also known as applicability, internal validity, [1] or fittingness) of a study. [2]
Good clinical data management practice (GCDMP) is the current industry standards for clinical data management that consist of best business practice and acceptable regulatory standards. In all phases of clinical trials , clinical and laboratory information must be collected and converted to digital form for analysis and reporting purposes.