Clinical Documentation Improvement Specialists Handbook

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9781601461469: Clinical Documentation Improvement Specialists Handbook
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Improving documentation is no easy task

CDI professionals have never had one easy-to-read, inclusive reference to help them implement a CDI program, understand the fundamentals of ICD-9-CM coding, query physicians, and encourage interdepartmental communication. In theory, physicians should document their entire thought process, including ruling conditions in and out. But it’s not that simple, and in light of MS-DRGs, it requires significant physician education and retraining. You need a blueprint for success..

Your blueprint has arrived!

At last, here is a guide for CDI specialists. The Clinical Documentation Improvement Specialist’s Handbook is your essential partner for creating a CDI program, staffing your program, querying physicians, and understanding how documentation affects code selection and data quality

As a CDI specialist you need answers now

In light of Medicare Severity DRGs (MS-DRG), detailed documentation and accurate capture of complications and comorbidities (CCs) has made the CDI specialist’s role more important and more demanding than ever. This handbook will enhance your ability to gather the right information the first time—and every time

Author Colleen Garry, RN, BS, has compiled case studies that document best practices and reference several different CDI models so that you can select the one that’s right for your hospital’s CDI success. In addition, you’ll be privy to an executive summary of HCPro’s exclusive CDI survey that solicited more than 800 responses. Learn how other hospitals are handling CDI and choosing the model that works best for them.

  • work with physicians to obtain detailed, appropriate documentation
  • maintain compliance when performing physician queries
  • convey return on investment for a CDI program

Customizable CD-ROM included

Your copy of The Clinical Documentation Improvement Specialist’s Handbook includes a CD-ROM loaded with all of the working tools you’ll find in the book. Among them are:

  • CDI specialist and manager job descriptions
  • Sample query forms
  • Pocket guide for severity CCs and clinical gold standard

Don’t take chances with any aspect of your CDI program

Hospitals are turning to CDI initiatives to ensure data quality and accurate reimbursement. This handbook is the blueprint you need, whether you’re starting a CDI program or enhancing an existing program. Learn how to obtain administrative and staff buy-in, engage clinical staff at the bedside to document the specific data you need for success, and maintain those efforts over time.

This book is a must-have for . . .

Clinical documentation improvement (CDI) specialists and managers, HIM managers, coders and coding managers, coding compliance managers, case managers, and revenue cycle managers.

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About the Author:

Colleen Garry, RN, BS, has implemented and managed a successful clinical documentation improvement (CDI) program at the Medical University of South Carolina for more than three years. She has recently accepted an assistant director clinical documentation position with New York University Medical Center.

Garry graduated from Marist College in New York and has a baccalaureate in Business Marketing as well as a Registered Nursing License. She has a varied background in nursing with more than 17 years of work experience as a critical care nurse, transplant coordinator, ESRD educator and, outpatient  program director. Prior to her career in healthcare, her business resume was accomplished with employment at IBM Corporation and NBC television in NY.

She is a member of the American Health Information Management Association, American Nurses Association, and serves on the board of HCPro's Association of Clinical Documentation Improvement Specialists. She has written articles for HCPro’s Medical Records Briefing and the Healthcare Finance Management Association newsletter The Business of Caring. She has spoken at various professional organizations about CDI programs.

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