JThomas_Clinical Documentation Worksheet_112623
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Rasmussen College, Florida *
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M208/HIM20
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Information Systems
Date
Dec 6, 2023
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HIM2000 Module 03 Assignment
Clinical Documentation
Instructions:
Thoroughly complete and submit this worksheet.
1.
Explain the purpose of
CDI.
To initiate concurrent, as needed retrospective reviews of
health records for conflicting, or nonspecific documentation
2.
List key CDI
stakeholders and
explain why they are
important to the
process.
Executive leadership: To help assist those within the care of
patients and direct staff as needed and help guide staff.
HIM & Coding departments: To obtain medical records and
process them appropriately and accordingly.
Compliance and Ethics: To ensure all documentation,
guidelines and policies are being followed.
Finance and revenue cycle: Helps with the processing of
medical bills to insurance companies and other revenue
outlets.
3.
Why are clear cut goals
critical for a successful
CDI program? Give a
couple of examples of
meeting goals.
Clear cut goals are critical for a successful CDI program because
of the need for accuracy in documentation for many purposes,
such as billing. Meeting a goal could be providing awareness and
education to providers whom do the documentation. That can
also help to promote health record completion which promotes
patient safety.
4.
What is the role of
queries in the CDI
process?
The roles of queries are to initiate and instill thorough
documentation.
5.
What is query
management?
Evaluation of the quality of healthcare
services and delivery using standards and
guidelines developed by various entities,
including the government and independent
accreditation organizations
6.
What are the CDI tools
and how are they used?
CDI QA. Helps monitor the work of a CDI professional.
Computer assisted coding and the EHR: Can be used to
help improve documentation, coding, data extraction
etc.
7.
What are CDI metrics?
What is the value of
metrics to the CDI
process? List 2 or 3
metrics that you feel
would be of most value
in a CDI program for
coders.
Measures to evaluate CDI programs, the organization,
and employees.
Review rate, query rate, response time, quality/revenue
impact.
8.
Explain the role of
physicians in CDI?
They are a liaison between the CDI staff, hospital
coders, CDS and the facility medical staff. Their role is
reviewing charts to identify areas for improvement in
HIM2000 Module 03 Assignment
documentation.
9.
Every CDI program
startup face challenges.
List the six (6)
challenges addressed in
the toolkit.
Administrative support
Physician buy-in and engagement
Training and education
Hiring right people in CDI positions
Budget
Staffing
10.Which challenge do you
think is the most
significant? Explain why.
I think they all are significant, if you are missing one or two
of the 6, that could be enough to put a stop to the program.
11.Every start-up program
requires data to make
decisions about what
the program needs to
address. Some
examples could include
at least 12 months of
DRG data, coding
issues, denial causes
and other case mix
data. What other
decisions have to be
considered and made
before implementing a
CDI program?
Budget, Training needs, who will train, Location of
training, Scope of practice, Alignment of the CDI
program, number and frequency of chart reviews, who
will comprise the CDI staff
12.Maintaining a successful
CDI program takes more
than just reviewing
patient charts to
validate DRG
assignment and working
with physicians. What
does a successful CDI
program require?
Effective plans are built on a foundation of purpose, vision,
mission, and short- and long-term goals. For a successful CDI
program to be maintained, a plan should be in place to
address the need for ongoing and/or updating education of
CDI professionals on ever-changing codes, rules, regulations,
and guidelines.
13.CDI programs require
skilled personnel.
What
are the skills or core
competencies needed
for a CDI Specialist?
Knowledge of medical record keeping. Medical
terminology, coding and procedures. Ability to
communicate effectively.
14.There are a number of
techniques CDI
professionals can use to
reduce denials. List four
Revenue cycle outsourcing, Varying payer guidelines,
Coding changes, Medical Necessity, modifiers
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