Mather Hospital is engaged in a project to ensure the clinical documentation within the health record accurately reflects the quality and delivery of care provided to our patients and supports the diagnosis and procedure codes assigned.
Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers. As such, clinical documentation improvement (CDI) programs are important to any facility that recognizes the necessity of complete and accurate patient documentation.
Better clinical documentation also has reimbursement implications. Making sure documentation is complete is even more important, now that insurers won't pay to treat many conditions unless the chart reflects the fact that the condition was present on admission.
Mather’s CDI involves many areas in the organization including Information Services, Health Information Management (HIM), Case Management, Revenue Cycle, physicians and other providers.
Any questions should be directed to Tom Heiman, VP, Information Services or Jenn Chamberlin, Director of Managed Care.
Did you know... There is no ICD-10 code for "Urosepsis"
This needs to be clarified as "Sepsis due to UTI"
Education Regarding Sepsis Documentation Improvement
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