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    Teks Presentasi Maju Be

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    Gita Fitrisia
    The document discusses Clinical Documentation Improvement (CDI). It defines CDI as a clinical documentation program staffed by clinical documentation specialists. The purpose of a CDI program is to ensure physicians provide complete, clear, reliable, and precise documentation in medical records. It describes the importance of clinical documentation for regulatory compliance and treatment. Seven criteria for high-quality clinical documentation are outlined as legible, reliable, precise, complete, consistent, clear, and timely. The role of a clinical documentation specialist to review records and ensure they meet standards is also summarized.

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    Teks Presentasi Maju Be

    Uploaded by

    Gita Fitrisia
    62 views3 pages
    The document discusses Clinical Documentation Improvement (CDI). It defines CDI as a clinical documentation program staffed by clinical documentation specialists. The purpose of a CDI program is to ensure physicians provide complete, clear, reliable, and precise documentation in medical records. It describes the importance of clinical documentation for regulatory compliance and treatment. Seven criteria for high-quality clinical documentation are outlined as legible, reliable, precise, complete, consistent, clear, and timely. The role of a clinical documentation specialist to review records and ensure they meet standards is also summarized.

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    teks presentasi uas be

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    The document discusses Clinical Documentation Improvement (CDI). It defines CDI as a clinical documentation program staffed by clinical documentation specialists. The purpose of a CDI program is to ensure physicians provide complete, clear, reliable, and precise documentation in medical records. It describes the importance of clinical documentation for regulatory compliance and treatment. Seven criteria for high-quality clinical documentation are outlined as legible, reliable, precise, complete, consistent, clear, and timely. The role of a clinical documentation specialist to review records and ensure they meet standards is also summarized.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    62 views3 pages

    Teks Presentasi Maju Be

    Uploaded by

    Gita Fitrisia
    The document discusses Clinical Documentation Improvement (CDI). It defines CDI as a clinical documentation program staffed by clinical documentation specialists. The purpose of a CDI program is to ensure physicians provide complete, clear, reliable, and precise documentation in medical records. It describes the importance of clinical documentation for regulatory compliance and treatment. Seven criteria for high-quality clinical documentation are outlined as legible, reliable, precise, complete, consistent, clear, and timely. The role of a clinical documentation specialist to review records and ensure they meet standards is also summarized.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Name : Gita Fitrisia

    Registration number : 20160310009

    Introduction
    Good morning my friends. My name is Gita Fitrisia. My registration
    number is 20160310009. I come from Faculty of Health Sciences, majoring
    Health Information Management. First of all, I want to say thanks to Miss Nargis,
    next I say thanks to all my friend.

    This moment I’d like to talk about Clinical Documentation Improvement


    (CDI). I choose this topic, because there are many people don’t know about CDI.

    In the first part of my presentation, I’ll describe about the concept of


    CDI, after that I’ll talk about importance of CDI, then I’ll explain about seven
    criteria for high-quality clinical documentation. Finally I’ll talk about the clinical
    documentation specialist.

    Before I stop my presentation, I will take some conclusions. I will be hapy


    if you ask me at the end of my presentation. Let me start.

    Body
    1. Concept of Clinical Documentation Improvement
    A clinical documentation program staffed by clinical
    documentation specialist. The ultmimate purpose of a CDI program is to
    ensure that physicians provide the most complete, clear, reliable, timely,
    legible, and precise documentation (information) consistent with the
    clinical findings (data) in the medical record. A CDI program includes
    review of patient records while the patient is still in the hospital to
    concurrently identify any opportunity for improvement in clinical
    documentation.

    2. The Importance of Clinical Documentation


    Clinical documentation is any manual or electronic notation (or
    recording) made by a physician or other healthcare clinician related to a
    patient’s medical condition or treatment. Clinical documentation is the
    primary menas clinicians use to communicate their opinions about a
    patient’s condition(s) and decisions about how treat the patient.

    Clinical documentation is important because clinical


    documentation in patient health records is highly regulated, the theory
    must begin with regulatory and legal requirements. Medicare Conditions
    of Participation require all healthcare providers to maintain patient health
    records and dictates certain content.

    3. Seven Criteria for High-Quality Clinical Documentation


    The seven criteria for hight-quality clinical documentation required that all
    entries in the patient record be:
    1. Legible : clear enough to be read and easily deciphered
    2. Reliable : Trustworthy, safe, yielding the same result when repeated
    3. Precise : Accurate, Exact, Strictly Defined
    4. Complete : Has the Maximum Content
    5. Consistent : Not Contradictory
    6. Clear : Unambigous, Intelligible; Not Vague
    7. Timely : At the Time of Service

    4. The Clinical Documentation Specialist


    Clinical documentation specialist is the individual who is chiefly
    responsible for reviewing the patient’s record to determine whether it
    meets the criteria for high-quality clinical documentation. Clinical
    documentation specialist must have strong skills in the following four
    areas:
    1. Healthcare regulations, including reimbursement and
    documentation requirements
    2. Clinical knowledge with training in pathology of disease
    processes
    3. Ability to read and analyze all information in a patient’s health
    record
    4. Communication with physicians and other clinicians.

    Conclusion
    1. Clinical Documentation Improvement (CDI) is a program include review
    any opportunity for improvement in clinical documentation
    2. Clinical documentation is important because clinical documentation in
    patient health records is highly regulated, the theory must begin with
    regulatory and legal requirements
    3. The seven criteria for hight-quality clinical documentation are legible,
    reliable, precise, complete, consistent, clear and timely.
    4. Clinical documentation specialist is the individual who is chiefly
    responsible for reviewing the patient’s record to determine whether it
    meets the criteria for high-quality clinical documentation.

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