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Four tips for clinical documentation improvement

Jonathan Elion, M.D., a cardiologist and associate professor of medicine at Brown University, has four tips for clinical documentation improvement in ambulatory settings.

They are:

  • “Define the exact patient and visit categories that you think merit inclusion in a CDI workflow.
  • “Determine how these patients can be identified by information in the HIS {hospital information system} and its associated electronic messages.
  • “Make sure that you can define your facility’s use of account numbers in open or recurring visits.
  • “Be specific about what you want to accomplish and how you will measure your progress.”

To read more, please hit this link.

How to pull physicians into clinical documentation



Todd J. Kislak, chief development officer for Hospitalists Now Inc.writes in Hospitals & Health Systems about how best to push and pull often reluctant physicians to get behind clinical documentation.

His suggestions include:

“Provide the physicians with real-time information while the patient is present.”

“Physician leaders at the facility must be visible, vocal and united in efforts to promote CDIs among the medical staff and the administrative team.”

“Physicians must be continually educated to view CDIs as first and foremost a quality mandate.”

“Encourage active engagement and team building between the physicians and the CDI team.”

“Formalize the hospital’s expectations by articulating physicians’ responsibilities in attaining CDI goals. ”

“Connect the CDI effort to the hospital’s overall physician engagement and development program.”


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