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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 ...
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]
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 ...
DCBA, Inc. DCBA, Inc. provides clinical audit and clinical documentation improvement programs. Healthcare Quality Improvement Partnership (HQIP) Promoting quality for better health services, HQIP is funded by the Department of Health to increase the impact that clinical audit has on healthcare quality in England and Wales. Clinical Audit Tool ...
The VHQC provides quality improvement assistance to Virginia's acute care hospitals and more than 700 physicians in a number of clinical topics such as heart failure, pneumonia, stroke, breast cancer and diabetes. In addition, the VHQC conducts many local and national projects that employ quality improvement techniques for at-risk populations.
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care.
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]
Lead or participate in the procurement, customization, development, implementation, management, evaluation, and continuous improvement of clinical information systems. Clinicians collaborate with other health care and information technology professionals to develop health informatics tools which promote patient care that is safe, efficient ...
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