Clinical Documentation Integrity
question with answers
Clinical documentation - -Clinical documentation is defined as any manual or
electronic notation made by a physician or other health care provider related to a
patient's medical condition or treatment. Therefore, clinical documentation is at the
core of every patient encounter. The patient record serves as the legal record for
the health care organization because it provides a lasting record of the patient's
history, diagnoses, tests, and treatments
Clinical documentation integrity (CDI) specialists - -Clinical documentation integrity
(CDI) specialists are the translators and validators of the health record who ensure
the information is complete and accurate
Clinical Documentation Integrity - -The policies, procedures, technology, and people
that promote complete and reliable provider documentation; essential for the
assignment of ICD-10-CM/PCS, CPT, and HCPCS codes for reimbursement for
services provided.
Important initiative by CMS 2008 - -CMS updated the Diagnosis Related Group
(DRG) payment mechanism to the Medicare Severity version (MS-DRG).
The chronic conditions (CC) list was completely revised
The requirement to report Present On Admission (POA) indicators was initiated.
Medicare Conditions of Participation - -A set of regulations setting minimum health
and safety standards for hospitals participating in Medicare.
Deemed status - -Status of hospitals accredited by the Joint Commission on
Accreditation of Healthcare Organizations or the Association of Osteopathic
Hospitals as "deemed" to meet the Medicare Conditions of Participation.
Legible - -A record that is clear enough to be read and easily deciphered.
Reliable - -means the content of the record is trustworthy, safe, and yields the same
result when repeated. This relates to the treatment provided to the patient and
whether the physician's documentation supports that treatment.
Precise - -A record that is accurate, exact, and strictly defined.
Complete - -A record that contains maximum content and is thorough, meaning the
physician has fully addressed all concerns in the patient record, including
authentication (signature and date).
Consistent - -It means the record contains no contradictory information.
Documentation deficiency - -Clinical documentation that contradicts itself from one
progress note to the next or among entries from different physicians has a
documentation deficiency.
question with answers
Clinical documentation - -Clinical documentation is defined as any manual or
electronic notation made by a physician or other health care provider related to a
patient's medical condition or treatment. Therefore, clinical documentation is at the
core of every patient encounter. The patient record serves as the legal record for
the health care organization because it provides a lasting record of the patient's
history, diagnoses, tests, and treatments
Clinical documentation integrity (CDI) specialists - -Clinical documentation integrity
(CDI) specialists are the translators and validators of the health record who ensure
the information is complete and accurate
Clinical Documentation Integrity - -The policies, procedures, technology, and people
that promote complete and reliable provider documentation; essential for the
assignment of ICD-10-CM/PCS, CPT, and HCPCS codes for reimbursement for
services provided.
Important initiative by CMS 2008 - -CMS updated the Diagnosis Related Group
(DRG) payment mechanism to the Medicare Severity version (MS-DRG).
The chronic conditions (CC) list was completely revised
The requirement to report Present On Admission (POA) indicators was initiated.
Medicare Conditions of Participation - -A set of regulations setting minimum health
and safety standards for hospitals participating in Medicare.
Deemed status - -Status of hospitals accredited by the Joint Commission on
Accreditation of Healthcare Organizations or the Association of Osteopathic
Hospitals as "deemed" to meet the Medicare Conditions of Participation.
Legible - -A record that is clear enough to be read and easily deciphered.
Reliable - -means the content of the record is trustworthy, safe, and yields the same
result when repeated. This relates to the treatment provided to the patient and
whether the physician's documentation supports that treatment.
Precise - -A record that is accurate, exact, and strictly defined.
Complete - -A record that contains maximum content and is thorough, meaning the
physician has fully addressed all concerns in the patient record, including
authentication (signature and date).
Consistent - -It means the record contains no contradictory information.
Documentation deficiency - -Clinical documentation that contradicts itself from one
progress note to the next or among entries from different physicians has a
documentation deficiency.
