Clinical Documentation Improvement Essay Assignment Paper
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.
- Explanation for step 1
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- 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.
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