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Clinical documentation improvement (CDI) ensures that health services are accurately documented and helps healthcare coders and physicians work toward improved patient care while also streamlining productivity.
When meaningful clinical data is captured, organizations can ensure improved quality reporting, clinician productivity, and even better clinical information delivered at the point of care.
Phoenix Children’s Hospital recently opted for CDI at its outpatient clinics with Medicomp Systems.
It’s important to help physicians make patient care faster, safer, and more efficient.
Every single symptom, sign, medication, surgery, drug, operation procedure, almost a repository of more than 360,000 terms, they have structured and coded with every possible common coding schema, such as ICD-10,” he continued.
Having 360,000 terms can be overwhelming, but they were built along disease patterns. If a physician entered that a patient had asthma, or tried to research asthma in the database, it went out to all related items that were related to asthma and it brought them together in a manner of an automatic template that was a quick, rapid initial draft.
There is no magic formula with clinical documentation and finding an applicable system for an organization.
“You cannot take shortcuts. You cannot not capture things that are critical and essential,”
