CDI Module
Clinical Documentation Improvement (CDI) is a process in the healthcare industry that focuses on enhancing the quality and accuracy of clinical documentation in medical records. ReviewMate has several options to assist in accomplishing your CDI goals:
- Concurrent CDI: This module will allow users to code and calculate DRGs from admission to discharge of the patient. The user can create as many sessions as needed to reflect each time the patient’s medical record is reviewed. Queries can be initiated in the system and the effectiveness of the queries can be tracked. The working DRGs can be tracked throughout the patient’s inpatient stay.
- Retrospective CDI: This module allows users to perform a coding audit where opportunities for query can be identified. The “Working DRG” can be entered by the user for comparison against the billed and audited DRG.
- CDI Clinician Screen: In the situation where a coder is performing an audit, and another CDI Clinician is also reviewing the same account, there is a screen where the clinician can enter their findings, recommend alternative DRGs and queries. This module allows users to see what the DRG would be with the documentation as it stands and what it would be with completed queries.
- Retrospective Query: In any audit, users can audit queries that were initiated in the past and are currently located in the medical record. AHIMA’s “Guidelines for Achieving a Compliant Query Practice” was used to create a series of Q&As to assure the query was compliant, open-ended and appropriate. Users can track the effectiveness of queries and turnaround times.
ReviewMate can play a critical role in ensuring that patient records accurately reflect the care provided, which has a positive impact on patient outcomes, financial reimbursement, research, and compliance with regulatory standards.
Clinical Documentation Improvement initiatives typically involve collaboration between healthcare providers, medical coders, clinical documentation specialists, and other relevant stakeholders. The goal is to improve the clarity, accuracy, completeness, and specificity of clinical documentation. This can be achieved through various methods, including:
- Education and Training: Healthcare professionals are educated about the importance of accurate documentation and provided with training on effective documentation practices.
- Queries: Clinical documentation specialists may collaborate with healthcare providers to clarify ambiguous or incomplete documentation by sending queries for clarification.
- Technology: Electronic Health Record (EHR) systems can support CDI efforts by providing prompts, reminders, and templates that encourage thorough and accurate documentation.
- Feedback and Reporting: Regular feedback is provided to healthcare professionals regarding the quality of their documentation. Reports on documentation accuracy and compliance can help identify areas for improvement.
ReviewMate will play a critical role in ensuring that patient records accurately reflect the care provided, which has a positive impact on patient outcomes, financial reimbursement, research, and compliance with regulatory standards.