Multi-Year KLAS Category Leader in CDI Software. Key Features in ChartWise: APR-DRG. EMR Integration. Mobile Query Delivery. NotePath NLP. NoteWise Rules Engine. Prioritization. Query Builder. Query Suggestions. RAF Calculator . Email us at [email protected]. or call 888-493-4502 and press 1 for support.

Clinical documentation integrity (CDI) programs help facilitate the precise representation of a patient’s clinical status. This is accomplished by reviewing health records to assure they meet high-quality clinical documentation standards that will translate into the appropriate coded data.

CDI (Clinical Documentation Improvement) is the process of improving medical record documentation for completeness, specifics, and accuracy.

Clinical Documentation Improvement (CDI) directly impacts patient care by ensuring medical records accurately reflect the full scope of a patient’s health status and care needs. This clarity supports better diagnoses, more tailored treatment plans, and …

A baseline CDI record review is a concurrent review of an inpatient medical record in which the CDI specialist attempts to abstract key information for the purposes of quality measurement, compliant coding, and appropriate reimbursement.

Specifically, CDI programs focused on improving clinical outcomes, reducing costs, and improving coordination of care across the healthcare continuum can significantly improve 30-day pneumonia mortality rates. This playbook provides a framework for …

Apr 15, 2015 · Review the medication history and compare it with what the physician ordered for the hospital stay. What is new? What is not ordered? What has been changed? Any changed dosage or route may indicate a chronic condition that is now acute. If your patient went to the operating room, review both the anesthesia record and the operation notes.

•Identify key relationships for successful Clinical Documentation Improvement (CDI) and Quality outcomes •Establish effective multidisciplinary communication and collaboration processes

3M™ M*Modal CDI Collaborate is a cloud-based clinical documentation integrity (CDI) solution used to enhance chart review and query workflow. Using advanced artificial intelligence (AI) and natural language understanding (NLU), it analyzes the entire electronic patient record to provide revenue cycle and health information management (HIM ...

Feb 28, 2023 · Core-CDI will conduct a complimentary inpatient medical record chart review consisting of 25 charts associated with known high-risk DRGs. The chart review will consist of 20 inpatient medical records and 5 inpatient medical records denied for medical necessity.