After flying, layover, college graduation, family time, more flying, running through the airport to make a connection and finally getting on the flight to San Antonio for the annual ACDIS conference, I began to wonder what it is about my drive and thirst [...]

The talk of Outpatient CDI has been going on since the fall of 2014 as we began to understand more about the impact of ICD-10 on the outpatient environment. Although the CPT codes will not be changing, the need to capture the correct ICD-10 code for the [...]

As I read this blog about “when to query”, it reminded me that there is no time like now when it comes to accurate, complete and compliant queries. With the evolving Electronic Health Record (EHR) it has become more important to query as soon as possible [...]

The term 'Clinical Documentation Improvement' has been around for many years and described the early work of the reasoning behind the program's start. The early implementation of CDI programs were sold to CFOs (Chief Financial Officers) as a way to [...]

I was reading an article today about healthcare reform and the affordable care act, which linked an increase in CDI staff with the increased use of electronic health records. I began to reflect on the past 10+ years in the Clinical Documentation [...]

Electronic health records continue to be instituted within hospitals in order to more efficiently capture the documentation of the patient story. In a recent article “Clinical Documentation in the 21st Century” we hear the position of the ACP (American [...]

CMS (Center for Medicare & Medicaid Services) has been working to decrease a number of conditions they feel should not happen while patients are in the hospital = HAC (Hospital Acquired Condition). The ACA (Affordable Care Act) created the HAC Reduction [...]