The Impact of Neonatal Abstinence Syndrome on Clinical Documentation
Jan23

The Impact of Neonatal Abstinence Syndrome on Clinical Documentation

While neonatal abstinence syndrome is a serious condition, the lack of a standard clinical definition makes it difficult for providers to recognize the symptoms and accurately diagnose and treat newborns. If the syndrome is not recognized, and thus not documented, then the correct diagnosis code will not be assigned—which in turn impacts the state and national statistics regarding this syndrome.

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Temporary Newborn Name Compliance: A Focus on Patient Safety
Dec27

Temporary Newborn Name Compliance: A Focus on Patient Safety

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).

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CDI: No Place for Complacency
Nov28

CDI: No Place for Complacency

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.

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It’s Complicated: Post-Operative Complications
Oct25

It’s Complicated: Post-Operative Complications

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.

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MDS Coordinators and Informatics: Own Your Expertise
Sep28

MDS Coordinators and Informatics: Own Your Expertise

The minimum data set (MDS) coordinator is a key player in a skilled nursing facility’s (SNF’s) team.

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Time for a Health Check on Physician Queries: How Mobile Technology Can Modernize CDI
Aug28

Time for a Health Check on Physician Queries: How Mobile Technology Can Modernize CDI

Hospital billing is complex and accuracy is critical, as it can affect not only reimbursement, but hospital and physician quality scores as well.

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