Clinical Documentation Improvement Program

Now is the time to launch or fine-tune your clinical documentation improvement. Not only is it one of the most critical elements of a successful ICD-10 transition, good clinical documentation is also a way to help your organization boost its revenue, improve the reliability of its patient data and change outcomes for the better.

HRS can help start your clinical documentation improvement (CDI) program—or revitalize a program already in place.

Implement best practices in clinical documentation now to ensure revenue and data integrity.

Image_CDIGraphic_300x238Regardless of the code set you're required to use, your revenue is driven by coding, and coding is driven by clinical documentation. Great clinical documentation also produces reliable data. As public scrutiny of quality and performance improvement initiatives intensifies, data accuracy will become more important than ever.

When documentation is too vague, resource-intensive queries and delays in billing can result. Additionally, coders may resort to “unspecified” codes, which can cause reimbursement to steeply decline. To get the right reimbursement and the right severity of illness and risk of mortality scores, your clinicians need to document with depth and precision. Specificity is key.

Start your documentation improvement program today with a custom clinical documentation gap analysis by HRS. We’ll review your clinicians’ health records for completeness and accuracy, and with this information develop a comprehensive training program. To ensure we’ve identified and addressed all gaps in your documentation, we’ll monitor your case mix index and queries, and provide further training if needed.

Start achieving the results you want.

HRS can help by providing an assessment of your clinical documentation practices that is tailored to the specific services you provide. And we’ll design our program to meet your timeframes and budget. HRS can also provide pre-tests for clients to gauge their knowledge of clinical documentation practices, as well as provide online analyses and training.

The HRS Clinical Documentation Improvement Program

Stage 1: Gap Analysis
HRS will analyze your documentation as it stands today, with highly skilled documentation specialists looking for patterns in documenting and querying compared to industry best practices.

Stage 2: Customized Education
Based on the gap analysis, HRS will design an education program specifically for your facility. This is no
standard education process. HRS will create lesson plans based on current needs and will only teach principles related to the service lines you offer.

Stage 3: Monitoring and Regulation
Once the education process is complete and the CDI program is in place, HRS will monitor facility case mix index, review queries and audit documentation to ensure best practices are being followed.

Assess your clinical documentation gaps now. Contact HRS online or call us at 800-329-0373.