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You are here > Home > Reading Lists > Nursing Management > Clinical Documentation Improvement Specialist's Handbook

Clinical Documentation Improvement Specialist's Handbook, 2nd Edition    
Ilene Macdonald, Colleen Garry, RN, BS

Softbound Book + CD-ROM  
Size: 8.5" x 11" book
ISBN 1601461461
978-1601461469
HCPro
May 2008
(click button below for the very best currently available price for this substantial resource)

 

Improving documentation is no easy task. CDI professionals have never before had one easy-to-read, inclusive reference to help them implement a CDI program, understand the fundamentals of ICD-9-CM coding, query physicians, and encourage interdepartmental communication.

In theory, physicians should document their entire thought process, including ruling conditions in and out. But it’s not that simple, and in light of MS-DRGs, it requires significant physician education and retraining.

You need a blueprint for success, and your blueprint has arrived! At last, here is a guide for CDI specialists. The Clinical Documentation Improvement Specialist’s Handbook is your essential partner for creating a CDI program, staffing your program, querying physicians, and understanding how documentation affects code selection and data quality.

In light of Medicare Severity DRGs (MS-DRG), detailed documentation and accurate capture of complications and comorbidities (CCs) has made the CDI specialist’s role more important and more demanding than ever. This handbook will enhance your ability to gather the right information the first time — and every time.

Colleen Garry, RN, BS, has compiled case studies that document best practices and reference several different CDI models so that you can select the one that’s right for your hospital’s CDI success. In addition, you’ll be privy to an executive summary of the exclusive CDI survey that solicited more than 800 responses. Learn how other hospitals are handling CDI and choosing the model that works best for them.

  • work with physicians to obtain detailed, appropriate documentation

  • maintain compliance when performing physician queries

  • convey return on investment for a CDI program

Customizable CD-ROM included! Your copy of The Clinical Documentation Improvement Specialist’s Handbook includes a CD-ROM loaded with all of the working tools you’ll find in the book. Among them are:

  • CDI specialist and manager job descriptions

  • Sample query forms

  • Pocket guide for severity CCs and clinical gold standard

Don’t take chances with any aspect of your CDI program. Hospitals are turning to CDI initiatives to ensure data quality and accurate reimbursement.

 

Learn how to obtain administrative and staff buy-in, engage clinical staff at the bedside to document the specific data you need for success, and maintain those efforts over time. This book is a must-have for: Clinical documentation improvement (CDI) specialists and managers, HIM managers, coders and coding managers, coding compliance managers, case managers, and revenue cycle managers.

 

Colleen Garry, RN, BS, is the clinical documentation manager at Medical University of South Carolina. She has the clinical background to understand the documentation process, and the CDI experience to unite CDI specialists, coders, and physicians into a strong and unified team.

With more than 18 years of experience, HCPro, Inc. is a leading provider of integrated information, education, training, and consulting products and services in the vital areas of healthcare regulation and compliance. The company's mission is to meet the specialized informational, advisory, and educational needs of the healthcare industry. As an acknowledged industry authority in healthcare regulation and compliance, HCPro focuses on providing its clients assistance and expertise in the areas of accreditation, medical staff affairs, credentialing, privileging, medical record management, regulatory compliance, nursing, quality/patient safety, infection control, and workplace safety.

(information from the publisher)

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