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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 ...
Ontario: 3M Clinical Documentation Improvement Specialist Program [330] Ontario: Fanshawe College in London [331] Ontario: HealthCareCAN/CHA Learning Health Information Coding Specialist in Ottawa [332] Ontario: HealthCareCAN/CHA Learning Health Information Management (in conjunction with Algonquin College) in Ottawa [333]
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
To be eligible for RHIA certification, an individual must complete a bachelor's degree in a health information management program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) or graduate from a foreign association that has a reciprocity agreement with AHIMA. [3]
The AAPC was founded in 1988, [6] as the American Academy of Professional Coders, with the aim of providing education and certification to coders working in physician-based settings. These settings include group practices and specialty centers (i.e. non-hospital settings).
A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information ...
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
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