Question 1:
- What is Clinical Documentation Improvement?
The success of a medical facility relies on the documentation that covers the client’s health records. Therefore, clinical documentation improvement (CDI) is significant in a healthcare facility. In this article, we are going to focus our study on CDI. Therefore, we have to define the term first before we consider its purpose. The term clinical documentation improvement (CDI) refers to the process of reviewing the clinical documents of the patient and relaying the feedback to the physician. However, the feedback is given to the physician that improves the document.
- What, if any, barriers exist to implementing the software?
A clinical documentation improvement is a software that is more reliable in billing. It ensures that the records are stored for review by the physicians with IT knowledge. However, just like any other software, implementation of CDI also encounters some barriers. However, the range of barriers that can result from the implementation ranges from the physician degree of understanding IT, timing and staffing. The software demands a high level of IT which the physicians did of study. Health care collages do not teach how to operate a CDI; the physicians learn it on their own. Timing is also another factor that imposes challenges on the implementation of the CDI. The inpatient CDI professionals are exposed to the long duration of reviewing the patient’s records while they are still in the remote areas. However, it is not possible to review the documentation of the inpatient and outpatient at the same time. Therefore, the system should be modified to run both records concurrently. Staffing is also a barrier to implementing a CDI program. The software reviews many documents at the same time hence reducing the staff responsibilities. Some staff members, therefore, may lack the opportunity to serve.
- What is the role of the HIM professional?
Health information (HIM) plays a significant role in the health care service. In the health service, HIM professionals are responsible for taking care of the patient’s medical data. The roles of HIM professionals include ensuring the safety of patients’ health records, integrity and quality in healthcare services. They also play another vital role in keeping clinical records such as therapy notes, nursing notes, among others.
Question 2
- The needs of the larger healthcare community/continuum as it relates to Clinical Documentation Improvement Software.
The need for clinical documentation improvement (CDI) software is to provide accurate clinical records of a patient. However, these records can be transformed into coded data. These codes are then written in the report cards of medical practitioners. The codes are then reimbursed in public health record where the trend of disease infection and intervention technique used. To this point, the CDI program has a great impact on both health care team, patient and their relative s who look after them.
Question 3
- What are the benefits of the system as listed on their web page?
Clinical documentation improvement (CDI) software plays a vital role in the field of medicine. It has eased the roles of medical practitioners and HIM professionals. However, clinical documentation improvement (CDI) software has various benefits which range from improving quality healthcare to keeping track of diseases. The first benefit is accuracy in recording patients’ health records. Effective CDI program displays a precise and accurate record of both patient and the caregiver. Another benefit of the CDI program is the provision of public health records, disease tracking, reimbursement and providing records of both inpatient and outpatient. It also enables of translation of the information in a coded form for future review.
- Is there a coding encoder system part of the system or available?
There is a coding encoder system component that is used to evaluate automated health information. It uses the encoder program, which remains as part of the program. However, it uses part of CDI to query and command the prompts which initiate communication between the software and the programmer. An encoder is, therefore, a software that is programmed to help in selecting codes.
- Are there any advantages of their system over others (as listed on their web page)?
Yes, there are several advantages to using the software. One of the advantages of using a database system over files is that there is no redundancy caused by data normalization. Another advantage is that there is no duplication, thus saving both storage and time.
- Any information available in prices, demonstrations, free trials, and implementation. Could you “see” inside the system on the vendor’s web site?
Many organizations indeed see good results with free trials. However, a vendor should not sell their free trials. Forcing free trials in new business may be dangerous to the growth of the business. However, the free single market strategy may not fit every vendor. Therefore, business people should insist on offering service at a price.
Question 4
In your table or an additional table, outline the database dictionary terms and definitions commonly used in the implementation of Clinical Documentation Improvement software in a Health Information Department.
- What items should be included in the reporting database according to the needs of the clinic as well as the broader health information community/continuum of care?
The items that need to be added in the database include enrollment, outpatient, and inpatient. However, the source claims are collected from “Data Elements for EHR Documentation,” online data obtained from the FORE Library Data body.
- Are their multiple definitions available for singular terms?
The word “data” is multiple in the sense that it shows information that reoccurs or reappears. From the clinical dictionary, data has dual features in the sense that it can refer to single information or a collection of data.