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Displaying records 1 to 20 out of 4326 results for "clinical documentation".
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SORT RESULTS BY: RELEVANCY | PUBLICATION DATE
JustCoding’s Clinical Conditions Encyclopedia is the perfect reso
OCTOBER 1, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
APRIL 9, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
JUNE 4, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
AUGUST 13, 2014
JUSTCODING
Incomplete documentation in patient clinical records can cause your organization legal and settle
SEPTEMBER 18, 2019
Providers don’t often receive education on clinical documentation, which can be a challenge
Increasing accountability in medicine has brought more attention to the importance of clinical do
SEPTEMBER 23, 2016
The new AHA Coding Clinic for ICD-10-CM and ICD-10-PCS cleared up some confusion regarding
ACDIS, the Association of Clinical Documentation Impro
APRIL 7, 2011
 Documentation
Using a streamlined approach to EHR documentation may help reduce stress for resident, according
AUGUST 7, 2015
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 19, 2016
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
AA best practice should identify clinical actions—assessment, teaching, procedures, coordin
Best practice should identify clinical actions—assessment, teaching, procedures, coordinati
The Association of Clinical Documentation Improvement Specialists (ACDIS), the premier healthcar
SEPTEMBER 10, 2012
Proper documentation is critical when it comes to supporting medical necessity and providing qual
HCPro Inc., a leader in healthcare education and training, and the Association of Clinical Docume
AUGUST 24, 2010
NOVEMBER 20, 2013
JUSTCODING
The first Clinical Documentation Improvement Week is taking place from September
SEPTEMBER 21, 2011
 Although documentation matters more and more in today?s world of ever-changing regulations, med
AUGUST 4, 2017
Q: I’m in a little debate: Does documentation of the patient’s body mass in
MAY 7, 2014
JUSTCODING
  Why are physician queries so critical to accurate documentation and coding? The an
The focus for clinical documentation improvement (CDI) specialists has historically been on the i
FEBRUARY 21, 2017
ACDIS, the Association of Clinical Documentation Improvement Specialists, the leading national as
FEBRUARY 8, 2011
Insufficient documentation is the leading cause of improper payments for claims involving referri
OCTOBER 28, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS) last week updated its
OCTOBER 13, 2015
by Kirsten Dize Strong documentation is key in home health, and implementation o
  A Comprehensive Error Rate Testing (CERT) study found insufficient documentation
JULY 22, 2015
JUSTCODING
To date, Clinical Learning Environment Review (CLER) visits are scheduled to occur every 18 to 2
OCTOBER 27, 2017
An outpatient clinical documentation improvement (CDI) program should be aligned with a fa
Medicare allows electronic signatures as “alternative signatures” on clinical records
The American Health Information Management Association (AHIMA) and the Association of Clinical Do
MARCH 11, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS) released a new position
NOVEMBER 5, 2014
By utilizing the information documented in the record, coders can report the BMI from a dietitian
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department tha
Clinical documentation is often overlooked during residency, yet without proper training, new ph
SEPTEMBER 9, 2016
Documentation example for coders in
OCTOBER 29, 2014
JUSTCODING
Documentation example in
MARCH 4, 2015
JUSTCODING
"[A]s we enter into clinical practice, physicians face the burdens of documentation and reg
SEPTEMBER 17, 2015
In the early days of clinical documentation improvement programs many staff members reported up t
Residency training typically serves as physicians’ first exposure to the clinical document
AUGUST 11, 2017
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that
Documentation Documentation
Coding and documentation should tell a patient's complete story. With the greater specific
At ACDIS, it’s no surprise when we hear about clinical documentation improvement efforts
HCPro, Inc., and ACDIS, the Association of Clinical Documentation Improvement Specialists, today
JUNE 15, 2011
Last Tuesday, NAHC submitted official comments to CMS on a pair of proposed clinical templates (o
Las Vegas, NV--Almost 400 clinical documenation specialists gathered in Las Vega
JUNE 2, 2008
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
FEBRUARY 11, 2015
JUSTCODING
No. The regulations do not mandate any particular form or format for documentation or confirmati
Q: Can you clarify the expectations related to documenting the discussion betwee
  CMS continues expand its ICD-10 Clinical Concepts Series for specialties on
AUGUST 26, 2015
JUSTCODING
Coders and clinical documentation improvement specialists need a clear understanding of how to us
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV)
Take a close look at the documentation guidelines that CMS suggests for the practice improvement
Q: Is the statement “please document in a progress note to capture the severity of i
ACDIS, the Association of Clinical Documentation Improvement Specialists
AUGUST 1, 2012
We all know that ICD-10 codes will require more complete documentation. We’ve been t
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty a
JULY 23, 2014
JUSTCODING
In recent years, hospitals have increasingly focused on creating clinical documentation improveme
ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS) creden
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
FEBRUARY 9, 2015
Q: I am looking for documentation or physician education tips related to ventilator manage
  Coders and clinical documentation improvement (CDI) specialists may not always a
JUNE 17, 2015
JUSTCODING
MARCH 19, 2014
JUSTCODING
APRIL 30, 2014
JUSTCODING
MAY 7, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
Documentation sample for coders in
NOVEMBER 12, 2014
JUSTCODING
MAY 13, 2015
JUSTCODING
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
NOVEMBER 20, 2013
JUSTCODING
Friday, April 11 is the deadline to apply for the Certified Clinical Documentation Specia
AUGUST 26, 2015
JUSTCODING
Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific
APRIL 9, 2014
JUSTCODING
OCTOBER 8, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whe
NOVEMBER 5, 2014
JUSTCODING
It’s an age-old question: How do you get physicians to support documentation improvement ef
by Kirsten Dize Make completing documentation in the home a requirement for all
Q: I am a coder in a hospital outpatient setting. Our physicians document drug use in s
JULY 22, 2015
JUSTCODING
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department t
NOVEMBER 12, 2014
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
DECEMBER 30, 2015
By James S. Kennedy, MD, CCS, CDIP The physician documented “encephalopathy&
MARCH 25, 2015
JUSTCODING
HCPro, Inc. and the Association of Clinical Documentation Improvem
New on JustCoding Platinum! New ICD-10-CM documentation examples in
JULY 9, 2014
JUSTCODING
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s pre
FEBRUARY 16, 2015
The Association of Clinical Documentation Improvement Specialists (ACDIS) honored the nation&rsqu
MAY 25, 2016
  Documentation standards
JANUARY 1, 2015
Q: The physician documented “encephalopathy” in the record of a patient who wa
Coders are tasked with telling a patient’s story based on the documentation in the m
MAY 20, 2015
JUSTCODING
Brian Murphy, Director of the Association of Clinical Docum
AUGUST 13, 2012
Q: In the past few weeks, we noticed physicians are documenting acute conge
CMS recently updated its Clinical Laboratory Amendments (CLIA) for lab work at critical access ho
APRIL 12, 2016
Q: The primary physician documented subacute cerebral infarction and I am wondering whethe
SEPTEMBER 23, 2015
JUSTCODING
APRIL 23, 2014
JUSTCODING
Focus on documentation. CMS believes it is the responsibility of the homecare provider to attempt
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone last weeke
Q: If a is patient admitted with malnutrition and the physician documented the patien
Most coders and clinical documentation improvement (CDI) specialists are familiar with the Unifor
JANUARY 14, 2015
JUSTCODING
MAY 6, 2015
JUSTCODING
The patient care plan (485) is not a stand-alone documentation system; it is the legal record of
JULY 29, 2015
JUSTCODING
ACDIS—the Association of Clinical Documentation Improvement Specialists—announced tod
MARCH 18, 2014
APRIL 23, 2014
JUSTCODING
Regardless of the clinical background of those responsible for reviewing documentation, it can be
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
Physician documentation for the use of osteogenic stimulators for nonunion of fractures is often
JANUARY 28, 2015
JUSTCODING
by Josh Poltilove Restructure clinical managers’ positions so they function
Q: Over the years I have heard differing opinions regarding whether clinical or coding exp
AUGUST 27, 2014
JUSTCODING
Ensure employee compliance with safety requirements in physician offices, clinics, and other faci
DECEMBER 23, 2014
  Creating a new position to assume a physician’s documentation duties may l
JULY 15, 2015
JUSTCODING
While many case managers today work closely with clinical documentation improvement (CDI) special
JANUARY 5, 2016
Announced in 2012, the ACGME’s Clinical Learning Environment Review (CLER) was established
JULY 21, 2017
A patient comes into the ED following an automobile accident. The physician documents that the pa
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
SEPTEMBER 3, 2014
JUSTCODING
APRIL 9, 2014
JUSTCODING
JUNE 4, 2014
JUSTCODING
In which format would you be most likely to access a clinical conditions library, which includes
JULY 9, 2014
JUSTCODING
In which format would you be most likely to access a clinical conditions library, which includes
JULY 16, 2014
JUSTCODING
OCTOBER 22, 2014
JUSTCODING
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 23, 2014
JUSTCODING
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 30, 2014
JUSTCODING
MAY 14, 2014
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 3, 2015
The proof of medical necessity strictly relies on the MD documentation and diagnosis and the skil
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
JANUARY 1, 2018
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
JANUARY 28, 2015
JUSTCODING
Documenting medical necessity has become a big topic over the last several years and there has be
MARCH 22, 2019
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
DECEMBER 1, 2017
The Association of Clinical Documentation Improvement Specialists (ACDIS) just launched a redesig
JUNE 20, 2016
The Association of Clinical Documentation Improvement Sp
OCTOBER 1, 2010
Although documentation matters more and more in today’s world of ever-changing regulations,
AUGUST 4, 2017
APRIL 9, 2014
JUSTCODING
By Christopher Cheney Vision-impaired hospital patients have worse clinical outcom
MAY 8, 2019
You’ve probably heard that you need to beef up your clinical knowledge for ICD-10-CM
Documentation: Getting the details right Joint Commission eli
DECEMBER 6, 2016
The Association of Clinical Documentation Improvement Specialists (
FEBRUARY 23, 2012
OCTOBER 8, 2014
JUSTCODING
Jeff comes in to the Fix ‘Em Up Clinic complaining of shortness of breath, a persistent cou
Agencies should consider implementing a Utilization Review (UR) model or a clinical manager as a
Managers should not assume that they can review every guideline, every item in Coding Clinic,
  Q&A: Documentation for body mass index
  Skilled Services: How to document for proper reimbursement
OCTOBER 9, 2015
  Featured member resource: ADR appeal documentation checklist
NOVEMBER 16, 2018
MAY 7, 2014
JUSTCODING
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, a
JUNE 11, 2014
JUSTCODING
Q: We are an independent outpatient end-stage renal disease clinic. When we administer a blo
NOVEMBER 11, 2015
JUSTCODING
NOVEMBER 19, 2014
JUSTCODING
APRIL 2, 2014
JUSTCODING
I’m always excited to read an article about clinical documentation improvement in the mains
SEPTEMBER 23, 2015
JUSTCODING
Bylaws serve as the governing documents of the medical staff. Bylaws must meet the hospital&rsquo
DECEMBER 13, 2013
As we update our Clinical Privilege White Paper library, I’m often amazed at how mu
JULY 23, 2014
JUSTCODING
JULY 30, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 3, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 10, 2014
JUSTCODING
SEPTEMBER 24, 2014
JUSTCODING
  A clinical learning environment review (CLER) visit to your facility is imminent
SEPTEMBER 12, 2014
Those interested in taking the Certified Clinical Documentation Specialists (CCDS) credential exa
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
Effective July 1, 2016, ACDIS will institute a policy and penalty fee for late Certified Clinic
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, Det
AUGUST 26, 2020
NOVEMBER 19, 2014
JUSTCODING
Many coders rely on the AHA's Coding Clinic advice to resolve sticky situ
MAY 13, 2015
JUSTCODING
Written by Renee Kinder, MS, CCC-SLP, RAC-CT, Director of Clinical Education at Encore Rehabi
Hazards posed by batteries and alcohol preps prompt a review of fire safety issues in clinics
Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his to
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 29, 2016
Compliance MSPs, physicians, and hospital-owned clinics:
Jeff, an 18-year-old male, came into the Fix ‘Em Up Clinic with complete left oculom
Documentation of terminal illness at admission and during the hospice service period must be deta
Documentation of terminal illness at admission and during the hospice service period must be det
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
The popularity and growth of retail medical clinics and pharmacies continue to increase. And now
JUNE 18, 2015
  CMS is rolling out the next version of Transforming Clinical Practice Initiative Support and
CMS issues 2014 annual update for Clinical Laboratory Fee Schedule and Laboratory Servi
  Have a question? Need to find a document? Not sure where to look? Watch this site demo now!
JANUARY 19, 2017
By Julie Mills, RN, MBA, senior manager, clinical solutions executive, PerfectServe
JANUARY 28, 2020
The following changes to the Certified Clinical Documentation Specialist (CCDS) credential
Can the plan of care serve as a way to document medications?  
DECEMBER 3, 2014
JUSTCODING
In addition to documentation by physicians, nurses’ documentation affects patient safety,
JANUARY 8, 2020
The National Practitioner Data Bank (NPDB) Final Regulations define clinical privileges as &ldqu
How many case managers and visit nurses do you recommend per clinical manager?
What documentation is necessary for a medication review? The regulation
SEPTEMBER 24, 2014
JUSTCODING
DECEMBER 3, 2014
JUSTCODING
Effective documentation of the condition and the patients’ co-morbidities may help lawyers
In December 2014, CMS posted a document on its Advisory Panel on Hospital Outpatient Payme
As retail clinics expand in number and in scope of services, they could emerge as a threat to som
HCPro is seeking feedback on your rural health clinic billing and compliance training needs. Plea
FEBRUARY 25, 2015
JUSTCODING
MARCH 26, 2014
JUSTCODING
We want physicians to be very clear in their documentation about what’s wrong with the pati
Coding Clinic's Fourth Quarter 2013 issue focuses considerable attention on ICD-10-
The Association of Clinical Documentation Improvement Speci
The Advanced CDI Boot Camp is designed for established clinical documentation depar
Q: Should I query for chronic respiratory failure if the documentation indicates the patient
SEPTEMBER 30, 2015
JUSTCODING
Medical staffs across the country are discovering their governance documents are inadequate for t
The sitemap of HCPro gives you convenient, once click access to each of our departments, e-Newsletters, newsletters, and blogs.
SEPTEMBER 4, 2008
New timeframe for response to additional documentation requests  
The number of retail health clinics in the U.S. continues to increase at a rapid clip along with
AHA’s Coding Clinic is ramping up its focus on ICD-10 and we’ll help
JUNE 18, 2014
JUSTCODING
Recently my local clinic announced it had joined the “family” of practices owned by
As retail clinics expand in number and in scope of services, they could emerge as a threat to som
By Cheryl Ericson, MS, RN, CCDS, CDIP Many clinical documentation improvement (CDI
JULY 29, 2015
JUSTCODING
Become more proactive. You no longer can wait for face-to-face documentation to arrive within sev
SEPTEMBER 23, 2015
JUSTCODING
Editor’s note: This is the second of a series of stories that will help medical clinics
The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission crea
SEPTEMBER 23, 2015
The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission crea
SEPTEMBER 8, 2015
Medicare Boot Camp®—Rural Health Clinic Version is a one-day intensive course on Medica
by Pedram Mizani, MD, MHSA, family physician and chief clinical officer of the AmeriClerkship
FEBRUARY 2, 2018
By: Christopher Cheney, Senior Clinical Care Editor at HealthLeaders During the
A regulatory loophole in Florida state law allows cash-only medical clinics to skirt the licensi
MARCH 27, 2014
CMS has terminated its Medicare agreement with Yorkville Endoscopy, a New York City clinic that
First-person accounts of clinical experiences help Massachusetts General Hospital (MGH) nurses re
MARCH 27, 2015
ACGME-accredited programs are required to establish a clinical competency committee (CCC) to eval
JULY 10, 2015
In a recent frequently asked questions (FAQ) document released by the Centers for Medicare &
Q&A: Managing LS, EC, and EM documentation Editor
DECEMBER 20, 2016
In the rush to complete ICD-10 coding education, documentation improvement, and system updates, H
OCTOBER 21, 2015
JUSTCODING
FEBRUARY 11, 2015
JUSTCODING
Thank you for being a loyal subscriber to HCPro's Long-Term Care Clinical Pearls. T
A new health clinic in Savannah, Georgia opened its doors this week to free visits for gov
AUGUST 7, 2014
A jury has convicted a physician and his clinic administrator on 19 counts of healthcare f
NOVEMBER 13, 2014
The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commiss
SEPTEMBER 16, 2015
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, De
SEPTEMBER 27, 2018
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, Det
APRIL 8, 2020
What should our clinicians document if the patient hasn't had the flu vaccine yet? The pa
Is it true that the following documentation is an improper certification statement on our
Provider-based clinics and departments are increasingly common at hospitals, but the rules for pr
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complica
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complica
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complication/co
CMS made incorrect payments to hospitals for established patient clinic visits estimated a
JANUARY 21, 2015
JUSTCODING
This week the ACGME announced a four-year initiative to promote improvements in the clinical lear
NOVEMBER 6, 2015
Medicare Boot Camp—Rural Health Clinic Version is a one-day intensive course on Medicare co
Medicare Boot Camp—Rural Health Clinic Version is a one-day intensive course on Medicare co
  Medical staffs are discovering their governance documents are inadequate for tod
SEPTEMBER 18, 2014
SEPTEMBER 9, 2015
JUSTCODING
WRITTEN BY LENA BROWNING, MHA, BSN, RN, A CONSULTANT AT clinical.com
by Deepak Gupta, MD, anesthesiology clinical assistant professor; and Sarwan Kumar, MD, inter
APRIL 28, 2017
Consider adopting clinical pathways to increase nursing visit efficiency, decrease rehospitalizat
Measure a wound from inside edge to inside edge to correctly document wound size, and ensure that
The clinical nurse leader role, introduced more than a decade ago as way to improve patient outco
APRIL 24, 2015
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complication/co
APRIL 22, 2015
JUSTCODING
A Virginia dermatology clinic
SEPTEMBER 6, 2016
We have been told that the following documentation would position us for a potential clai
The Wisconsin Department of Health Services awarded the Mayo Clinic Health System in Eau C
DECEMBER 19, 2014
A petition calling on the National Board of Medical Examiners to end the Step 2 Clinical Skills e
APRIL 1, 2016
The Mayo School of Graduate Medical Education at Mayo Clinic in Jacksonville, Florida, is using a
APRIL 15, 2016
What pitfalls can you avoid to ensure proper documentation? These are eight common mistakes made:
JANUARY 28, 2020
The documentation surrounding your QAPI program should include:  
These Occupational Health and Safety Forms provide you with all of the updates for your OSHA Health and Safety Compliance Manual.
DECEMBER 17, 2008
True or false: When a patient has been seen in the outpatient clinic for a minor eye infection an
DECEMBER 2, 2014
By Christopher Cheney, HealthLeaders Media Cancer clinics are mak
APRIL 30, 2020
MAY 21, 2014
JUSTCODING
DECEMBER 23, 2014
JUSTCODING
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, Det
JUNE 24, 2020
By Megan Batty Ensure that medical record documenta-tion clearly documents a canc
MARCH 5, 2014
JUSTCODING
Two new conditions in our clinical-conditions-encyclope
NOVEMBER 5, 2014
JUSTCODING
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complication/c
A patient has the right to access his or her clinical information, request a copy of his or her
The ACGME’s Clinical Learning Environment Review (CLER) program aims to provide feedback to
JANUARY 6, 2017
 A first-year resident training at the Cleveland Clinic has been fired after multiple anti-S
JANUARY 4, 2019
In light of the COVID-19 pandemic, large hospital chains in California have discontinued clinical
MARCH 18, 2020
Local ACDIS chapters provide a vital networking and educational service to clinical documentation
On April 10, 2020, CMS issued a proposed ruledocuments/2
The electronic document management system (EDMS) plays a role in designing the official legal h
Nurses new to home health struggle with the completion of documentation related to patient care.
CMS doesn't require Medicare Advantage plans to have a face-to-face document for home health. Bu