CDI best practices: Capturing the true clinical story

CDI best practices: Capturing the true clinical story

July 09, 2019
Health IT
• Query policies: This should include when, how and what to base a query on
• Escalation policy: This is an essential policy to ensure unanswered queries and other issues have documentation of the proper channels to follow

Involve a physician advisor
The role of a physician advisor, or champion, is highly recommended. This role is the bridge between the CDI team and the medical staff. This role can assist with the education process and physician engagement. If the physicians are not engaged and educated on the importance of CDI, there may be issues with physician responsiveness to queries.

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About the author: Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA, is the AHIMA director for HIM practice excellence.

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