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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 ...
[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
Some medical coders elect to be certified by more than one society. The AAPC offers the following entry-level certifications in the U.S.: Certified Professional Coder (CPC); which tests on most areas of medical coding, and also the Certified Inpatient Coder (CIC) and Certified Outpatient Coder (COC). Both the CPC and COC have apprentice ...
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 ...
Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions.
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
In particular the paper medical record standard 'AS 2828' created by Standards Australia focuses on a few key areas that are critical to maintaining a legible paper medical record. [7] The following criteria should be used as a guideline when creating a medical record specific to the aid of providing clear documentation for diagnostic coding.
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
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