Assigning newborns temporary names at birth is a common practice for hospitals. As a result, a large volume of patients with similar identifiers could potentially result in duplicate records and increase the risk for sentinel events (e.g. circumcision performed on wrong patient).
The evidence for almost any diagnosis can be argued regarding the given variables within a record. This applies to both CDI professionals seeking to add diagnoses and auditors seeking to remove them.
The challenge for clinical documentation improvement specialists is in determining if the condition is an expected outcome of the procedure or patient’s disease process, or if it is an actual post-operative complication.
The minimum data set (MDS) coordinator is a key player in a skilled nursing facility’s (SNF’s) team.
Hospital billing is complex and accuracy is critical, as it can affect not only reimbursement, but hospital and physician quality scores as well.
As the current healthcare paradigm continues to shift to value-based care models with an outpatient emphasis, addressing outpatient clinical documentation is prudent.