Clinical Documentation Improvement (CDI) 2023 passed

Clinical Documentation Improvement (CDI) Clinical Documentation Improvement (CDI) - correct answer Process an organization undertakes that will improve clinical specificity خصوصية and documentation that will allow coders to assign more concise disease classification codes. The data quality attributes essential to CDI - correct answer 1.Precision دقة 2. Comprehensiveness. 3. Consistency تماسك 4. Accuracy دقة 5. Timeliness Precision دقة - correct answer documentation supports the purpose of the health record Comprehensiveness: - correct answer complete with maximum content, including the importance data having an impact on decisions made for patient treatment / care. Consistency تماسك - correct answer documentation is reliable and has the same information in all parts of the health records Accuracy دقة - correct answer documentation is free of any identifiable errors Timeliness: - correct answer documentation is up-to-date What may result from improved clinical documentation? - correct answer 1. Reduced risk associated with healthcare compliance. 2. Minimized vulnerability to external audits, such as the Recovery Audit Contractors. 3. Identify areas that may indicate quality of care issues. 4. Improve reporting for quality measures, present of admission indicator, pay for performance programs, value-based purchasing, data used for decision-making in reimbursement methodologies, and better information for reporting the patient care provided. The core designated clinical documentation set for coding compliance in the acute care inpatient health record: - correct answer 1. Attending physician documentation. 2. Other provider documentation. 3. Diagnostic test results, Pathology reports Attending physician documentation: - correct answer H&P, problem list, progress notes, orders, operative reports, discharge summary. Other provider documentation: - correct answer 1. Consultants 2. House staff physicians 3. Nurses and other specialty professionals problem list - correct answer Is one document that is important to both inpatient and outpatient clinical documentation. Updating this list to indicate whether the problem is active or inactive is crucial to the quality of patient care. medication list - correct answer In outpatient records, it is significant because it should be reconciled إصلاح on each outpatient encounter. Medications that are no longer taken by or prescribed for the patient should be updated to show this fact in the record. Ethical standards for CDI (Professionals behavior) Elements: - correct answer 1. Facilitate accurate, complete, and consistent clinical documentation within the health record to support coding and reporting of high-quality data. 2. Support reporting of all healthcare data elements completely & accurately. 3. Refuse to participate in fraudulent activities. 4. Facilitate interdisciplinary collaboration. 5. Advance professional knowledge through continuing education. 6. Refuse to participate in unethical reporting practices.