“Accurate documentation is at the core of telling that patient’s story and ensuring safe and effective care,” said AHIMA CEO Lynne Thomas Gordon. “This goes beyond more accurate reimbursement to understanding how improved documentation benefits patient care. CDI programs are necessary for consistent and complete documentation.”
To fully benefit from meaningful use and ICD-10 programs, healthcare providers should look at data collection as a comprehensive initiative to ensure safe and effective patient care, according to the statement.
To improve information capture, a recent AHIMA report from their 2014 CDI summit outlines seven best practices:
- Record patient safety indicators and quality management precisely using the CDI program.
- Check that the correct people, processes and technologies are being utilized.
- Keep CDI uniform throughout the organization.
- Track success with specific metrics: query rate, query quality, complication and major complication capture rates, CDI productivity and physician specific query rate.
- Utilize the diagnosis related group coordinator to assess hospital acquired conditions and patient severity.
- Provide ample training for high-performing physicians.
- Arrange for peer guidance between physicians.
More articles about clinical documentation improvement:
4 things hospitals can do to gain a competitive edge while preparing for ICD-10
Three ways to cut audit management costs: Leading health systems speak out
ICD-10 check-in: Where are healthcare stakeholders in the preparation process?
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