Clinical documentation (CD) is the formation of a digital or analog record reflecting a medical treatment, medical trial, or clinical test. Optimal clinical documentation helps in providing quality care and optimizing revenue cycle management in hospitals and health systems, which are thriving under value-based reimbursement.
Clinical documentation improvement (CDI) is a process of improving medical data collection to maximize claims reimbursement revenue and enhance the quality of care. CDI programs reassure that the medical record documentation presents an appropriate picture of the patient’s diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care.
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Clinical documentation integrity (CDI) programs have proven to be highly successful at ensuring patient stories are fully documented, and reimbursement is appropriate. However, when physicians need to return to a patient record to answer retrospective queries, they often see it as administrative burden that leads to even more burnout.
In this session, Kory Anderson, MD, and Kearstin Jorgenson from Intermountain Healthcare will discuss how they work with their teams to address this longstanding challenge with a transformational approach to CDI. You’ll learn how the patient-centric structure that underpins their physician-led CDI program keeps patient and physician well-being at the center of what they do. Don’t miss how the adoption of advanced AI brings physician and CDI workflows together and supports physicians at the point of care as they document in the EHR. Finally, you’ll learn about Intermountain Healthcare’s strategy for physician education and buy-in, and how the organization uses data to drive continuous improvement.
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