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Clinical Documentation Improvement Essay Assignment Paper
Question

Your organization is in the process of implementing a clinical documentation improvement (CDI) program. The newly appointed CDI director has made it clear that she is not interested in having input from the Health Information management department on the program's development. However, in your role as HIM director, someone has made you aware of a CDI policy stating that that once a query is answered and the information passed on to coder, the query from will not be retained.
Consider how to approach the CDI director with your differing opinion on this policy. Be sure to justify the position that you take.

Step 1/1

Introduction
Clinical documentation improvement (CDI) is a critical component of healthcare, which aims to ensure that the documentation accurately reflects the patient's medical condition and the services provided. Clinical Documentation Improvement Essay Assignment Paper

Explanation for step 1

. Introduction
Clinical documentation improvement (CDI) is a critical component of healthcare, which aims to ensure that the documentation accurately reflects the patient's medical condition and the services provided. CDI programs have become increasingly important due to the transition to value-based care, which emphasizes quality outcomes and accurate reporting. However, implementing a CDI program requires collaboration and coordination between different departments, including Health Information Management (HIM). In this scenario, the newly appointed CDI director has expressed disinterest in input from the HIM department, which has raised concerns about the program's success. Additionally, the CDI policy states that once a query is answered, it will not be retained, which may contradict the HIM department's policies. This paper discusses how to approach the CDI director with a differing opinion on this policy and justifies the position taken.
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Approach to CDI Director
When approaching the CDI director about the policy, it is essential to be respectful and diplomatic. It is crucial to express the intention of collaborating to ensure the success of the program. The HIM director could start by scheduling a meeting with the CDI director to discuss the policy and explain the reasons why retaining queries is crucial. The HIM director should explain that retaining queries is essential to track the effectiveness of the CDI program and to identify opportunities for improvement. Additionally, retaining queries can provide insight into the quality of the documentation and identify any areas that require further education or training.
Justification for the Position
The HIM department's policy of retaining queries is based on several justifications that could be presented to the CDI director. Firstly, retaining queries can help identify trends and patterns that may require attention. For example, if multiple queries are related to a particular diagnosis or procedure, it may indicate that the documentation needs improvement in that area. Secondly, retaining queries can provide valuable feedback to the clinical staff and improve their understanding of documentation requirements. Thirdly, retaining queries can help identify potential compliance issues, such as upcoding or under coding. If a query is related to a documentation deficiency that results in a higher reimbursement, it could indicate a compliance issue that needs to be addressed. Finally, retaining queries can help measure the effectiveness of the CDI program. By tracking the number and type of queries generated, the program's impact on documentation accuracy and quality can be measured over time.

Potential Objections
The CDI director may raise objections to the HIM department's policy of retaining queries. Some of the objections may include the following:

Privacy Concerns: The CDI director may be concerned about retaining queries due to potential privacy concerns. Queries may contain sensitive patient information, and retaining them could be a breach of patient privacy. In response, the HIM director could explain that the queries will be de-identified and only used for program improvement purposes.
Inefficient use of Resources: The CDI director may argue that retaining queries is an inefficient use of resources and may take up valuable staff time. In response, the HIM director could explain that the queries can be automated and analyzed using computer-assisted coding (CAC) or natural language processing (NLP) tools. These tools can quickly identify trends and patterns and highlight areas that require attention.
Incompatibility with the CDI Program: The CDI director may argue that retaining queries is incompatible with the CDI program's goals and objectives. The CDI program may focus on generating queries to improve documentation accuracy, and retaining them may not align with the program's goals. In response, the HIM director could explain that retaining queries is an essential component of the CDI program's success. It can provide valuable feedback to the clinical staff and help identify opportunities for program improvement.

Final answer

Conclusion
In conclusion, implementing a successful CDI program requires collaboration and coordination between different departments, including HIM. Clinical Documentation Improvement Essay Assignment Paper

Expert Answer

Clinical Documentation Improvement Essay Assignment Paper

Question

Your organization is in the process of implementing a clinical documentation improvement (CDI) program. The newly appointed CDI director has made it clear that she is not interested in having input from the Health Information management department on the program's development. However, in your role as HIM director, someone has made you aware of a CDI policy stating that that once a query is answered and the information passed on to coder, the query from will not be retained. Consider how to approach the CDI director with your differing opinion on this policy. Be sure to justify the position that you take.

Step 1/1

Introduction

Explanation for step 1

. Introduction

Clinical documentation improvement (CDI) is a critical component of healthcare, which aims to ensure that the documentation accurately reflects the patient's medical condition and the services provided. CDI programs have become increasingly important due to the transition to value-based care, which emphasizes quality outcomes and accurate reporting. However, implementing a CDI program requires collaboration and coordination between different departments, including Health Information Management (HIM). In this scenario, the newly appointed CDI director has expressed disinterest in input from the HIM department, which has raised concerns about the program's success. Additionally, the CDI policy states that once a query is answered, it will not be retained, which may contradict the HIM department's policies. This paper discusses how to approach the CDI director with a differing opinion on this policy and justifies the position taken.

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Approach to CDI Director

When approaching the CDI director about the policy, it is essential to be respectful and diplomatic. It is crucial to express the intention of collaborating to ensure the success of the program. The HIM director could start by scheduling a meeting with the CDI director to discuss the policy and explain the reasons why retaining queries is crucial. The HIM director should explain that retaining queries is essential to track the effectiveness of the CDI program and to identify opportunities for improvement. Additionally, retaining queries can provide insight into the quality of the documentation and identify any areas that require further education or training.

Justification for the Position

The HIM department's policy of retaining queries is based on several justifications that could be presented to the CDI director. Firstly, retaining queries can help identify trends and patterns that may require attention. For example, if multiple queries are related to a particular diagnosis or procedure, it may indicate that the documentation needs improvement in that area. Secondly, retaining queries can provide valuable feedback to the clinical staff and improve their understanding of documentation requirements. Thirdly, retaining queries can help identify potential compliance issues, such as upcoding or under coding. If a query is related to a documentation deficiency that results in a higher reimbursement, it could indicate a compliance issue that needs to be addressed. Finally, retaining queries can help measure the effectiveness of the CDI program. By tracking the number and type of queries generated, the program's impact on documentation accuracy and quality can be measured over time.

Potential Objections

The CDI director may raise objections to the HIM department's policy of retaining queries. Some of the objections may include the following:

Privacy Concerns: The CDI director may be concerned about retaining queries due to potential privacy concerns. Queries may contain sensitive patient information, and retaining them could be a breach of patient privacy. In response, the HIM director could explain that the queries will be de-identified and only used for program improvement purposes.
Inefficient use of Resources: The CDI director may argue that retaining queries is an inefficient use of resources and may take up valuable staff time. In response, the HIM director could explain that the queries can be automated and analyzed using computer-assisted coding (CAC) or natural language processing (NLP) tools. These tools can quickly identify trends and patterns and highlight areas that require attention.
Incompatibility with the CDI Program: The CDI director may argue that retaining queries is incompatible with the CDI program's goals and objectives. The CDI program may focus on generating queries to improve documentation accuracy, and retaining them may not align with the program's goals. In response, the HIM director could explain that retaining queries is an essential component of the CDI program's success. It can provide valuable feedback to the clinical staff and help identify opportunities for program improvement.

Final answer

Conclusion

In conclusion, implementing a successful CDI program requires collaboration and coordination between different departments, including HIM. Clinical Documentation Improvement Essay Assignment Paper

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