2010 Clinical Chart Review Track: ACDIS Conference Audio Recording
On-demand audio recordings of the Clinical Chart Review track of the
Association of Clinical Documentation Improvement Specialists' Third Annual Conference
held June 3-4, 2010, in Chicago
This event featured nationally recognized experts and in-the-trenches healthcare providers addressing key issues in clinical documentation improvement (CDI), with practical and innovative approaches for CDI success. Now through these on-demand recordings, you can bring the same great training presented at the Chicago event to your team, ensuring everyone has the same foundation to strengthen your organization's CDI program and ensure success.
The Clinical Chart Review track was one of three tracks presented. For information on the Program Management track or the New Initiatives and Ideas track, please click the appropriate link. You may also purchase all three tracks in a package that includes three general sessions:
- CDI in 2010: Spotlight on Compliance (by Catherine O’Leary and Gloryanne Bryant)
- Gray Areas in CDI: Negotiating the Relationship (by Dr. James Kennedy)
- Question and Answer Panel Discussion
Clinical Chart Review track topics:
Clinical Chart Review Clinical Potpourri: A Review of Problematic Diagnoses
William E. Haik, MD
Every day, CDI specialists have to sift through medical records and make sense of complex diagnoses, many of which are documented in “physician speak.” Taught by a physician, this session provides a brief, quick-hitting overview—no more and no less than what you need to know—to recognize and clarify diagnoses such as respiratory failure, pneumonia, and acute blood loss anemia.
Ethics Ends with the Clarification
Robert S. Gold, MD
CDI specialists should query physicians only when the diagnosis for which they’re seeking clarity is supported by clinical evidence in the medical record. This session focuses on taking a compliant approach to physician clarifications, with a particular focus on high-risk diagnoses.
CDI and the ED: Understand Physician Thinking to Conquer Documentation Challenges
Pamela P. Bensen, MD, MS, FACEP
Emergency department (ED) notes are among the most critical part of the medical record, as they help establish diagnoses that are carried throughout the patient’s stay. But they are frequently neglected or incomplete. Presented by a physician with more than 30 years of practice in emergency medicine, this session covers common ED roadblocks and challenges and helps participants understand physician thinking patterns.
Best Practices at University of Washington Medical Center: Care Documentation as a Clinical Process
Melinda Tully, MSN, CCDS and Holly Flynn, RN, CCRN
Recently, the University of Washington Medical Center (UWMC) made it a further priority to more fully integrate RN documentation specialists into the clinical team as the hospital moved to improve diagnosis clarification using an electronic health record. The presentation includes an in-depth case study of UWMC’s development of an expert level CDI program resulting in a comprehensive, clinically integrated, collaborative model.
The Power of Case Studies: Death Review and SOI/ROM
Cheryl Ericson, MS, RN
Case studies can be used to increase the proficiency of the CDI staff as well as to elicit the cooperation of the medical staff. Learn how one facility used this approach to develop an effective, comprehensive review of its death charts to dramatically improve its severity of illness (SOI)/risk of mortality (ROM) scores.
Risk Adjustment Methodology for Medicare’s Outcome Indicators
Kristen Geissler, MS, PT, MBA, CPHQ
Several of the measures included in Medicare’s ‘pay-to-report’ program—30-day mortality, 30-day readmission, and selected AHRQ Patient Safety Indicators—use risk adjustment methodology to account for differences in the severity of illness of patients across different hospitals. This session teaches CDI specialists how to query physicians to potentially improve outcome measure rates.
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