In “Clinical Documentation Improvement: Principles and Practice,” author Pamela Carroll Hess provides a comprehensive guide to understanding and implementing effective clinical documentation improvement (CDI) programs. With the transition to ICD-10 coding and the increasing focus on accurate and complete healthcare documentation, this book is an essential resource for healthcare organizations and professionals.

The book begins with an in-depth exploration of the fundamentals of clinical documentation, emphasizing the importance of assessing the current quality of documentation and making informed decisions about program implementation or improvement. Hess explains how a strong CDI program can positively impact various stakeholders, from patients and clinicians to coding professionals and reimbursement entities. By addressing the needs of each user, she demonstrates the value of implementing and maintaining a robust CDI program.

Part 2 of the book dives into the practical aspects of implementing a clinical documentation program. Hess offers guidance on staffing and training, effectively querying physicians, analyzing program data, and ensuring program compliance. This section provides valuable insights into the day-to-day operations of a CDI program and offers practical strategies for success.

In the final part of the book, Hess focuses on the growth and refinement of a clinical documentation program. She outlines a process for continuous improvement and provides recommendations for leveraging technology solutions to enhance CDI efforts. Hess also includes a chapter on critical thinking skills for physicians, nurses, clinical documentation specialists, and coders, highlighting the importance of accurate and comprehensive documentation in healthcare decision-making.

One of the standout features of this book is its relevance to the transition to ICD-10 coding. Hess highlights specific coding scenarios that will be impacted by the change and offers guidance on how to navigate the new coding system effectively. This makes “Clinical Documentation Improvement” an invaluable resource for healthcare professionals preparing for the transition.

Additionally, the book includes new material on CDI technology solutions, an example query set, and work plans for CDI program implementation, APR-DRG CDI program, and denials management. Hess emphasizes the importance of CDI program analytics and provides extensive guidance on how to measure and improve program outcomes.

Overall, “Clinical Documentation Improvement: Principles and Practice” offers a comprehensive and practical guide to implementing and sustaining effective CDI programs. The book is well-organized and written in a clear and concise manner, making it accessible to a wide range of healthcare professionals. Whether you are a coding professional, a nurse, a physician, or a clinical documentation specialist, this book will equip you with the knowledge and tools necessary to improve clinical documentation in your organization.

Order Now and Enhance Your CDI Program

If you are looking to improve the quality and accuracy of clinical documentation in your healthcare organization, “Clinical Documentation Improvement: Principles and Practice” is a must-read. By implementing the principles and strategies outlined in this book, you will not only ensure compliance with coding requirements but also enhance patient care and reimbursement outcomes.

Order your copy of “Clinical Documentation Improvement: Principles and Practice” today and take the first step towards optimizing your CDI program. With its comprehensive coverage and practical approach, this book is an essential resource for healthcare professionals dedicated to improving clinical documentation.