Clinical Documentation Improvement Project

Monday, April 20, 2009 at 2:07:37 PM

Clinical Documentation Improvement is a process for clarifying documentation on inpatients for severity of illness, risk of mortality, and reimbursement purposes. Coders are reviewing the documentation while the patients are inhouse and asking for clarification from providers if necessary. Primary queries are for complications or co-morbidities. How documentation is completed matters! For example, bacteremia doesn't have the same impact as sepsis, or CHF versus acute systolic heart failure. Please be aware that the documentation needs to be incorporated into the chart. If the query isn't answered by the time the patient is discharged, it should be addressed within the document imaging system. They are referenced in the Reason field in the bottom left as you are completing their records.

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