Question

A 4.25 Query retention

Your organization is in the process of implementing a clinical documentation improvement (CDI) program. The newly appointed CDI director has made it clear that she is not interested in having input from the HIM department on the program's development. However, in your role as HIM director, someone has made you aware of a CDI policy stating that once a query is answered and the information passed on to the coder, the query form will not be retained.

Consider how to approach the CDI director with your differing opinion on this policy.

Be sure to justify the position that you take.

Answer 1

As Health information management (HIM) professionals our highly trained in the business of Healthcare. Health information manager is responsible for planning, organizing, overseeing, and following up on all activities related to the HIM department that the integrity of clinical and financial data. They are responsible for ensuring that providers can access accurate and complete health information when and where they need.

Clinical documentation improvement(CDI).The CDI specialist is is responsible for conducting clinical based concurrent and retrospective reviews on inpatient medical records to evaluate. And to identify obtained clarification for the appropriate principal diagnosis, secondary diagnoses and principal procedure

Then , to approach the CDI director with the different opinion of this policy needs to convey that is as follow:

›Clinical documentation improvement(CDI)- Perspective.

›An Effective CDI program

Core Focus:compliance

Benifits

Elements

Mitigation of compliance risks

* H I M professionals have been querying physicians for more complete patient information for decades

However,More about HIM professionals that may help to trust or improving interest for having input from H I M department on the program's development

The health information managers work in clinical and administrative. Setting and often collaborate with physicians, nurses, executive officers and case workers. A director of health information management may supervise the work of medical records and health information technicians.

- Skills every Director of Health information have:

A director of health information management is expected to have a thorough understanding of Technology and practices that ensure data accuracy and accessibility, helping to improve efficiency in health care operations. They are typically skilled in health Information Systems analysis and design, Healthcare information security, Healthcare IT administration and other areas. And an industry involves, a director of health information management must keep track of clinical trends, government regulations and Healthcare management best practices

Because the Director of Health information management will interact with physicians, administrator and other Healthcare staff daily,. Communication skills are essential to the role. An executive at the highest level of Healthcare organization may turn to a director of health information management for advice on Healthcare Technology best practices, health information policies and Technology Investments. Therefore, presentation skills are a Core competency that employers seek out. Similarly, physicians rely on health information, so the ability to the listen and understand their need to be useful for building systems that help them ensure proper patient care and deliver better outcomes.

- As a problem-solving professional, Director of Health information management must be able to think through issues that may arise. Within their purview,A Director of Health information management identifies the questions to define problems and solutions

Leadership skills to manage teams, the ability to set high professional standards, and a desire to companion ethical practices are additional skills employers seek in the director to health information management candidates.

* And these leads to the CDI program:

To obtain accurate and complete medical record documentation through a a concurrent review process that reflects a patients true severity of illness

Benifits:

- Stronger compliance. Complete and accurate documentation process in accordance with CMS rules and regulations; provide a defence or regulatory compliance reviews

- Accurate quality ratings. More accurate reflect the true clinical picture of patience showing improve quality ratings

- Accurate expected length of stay. More accurately reflect expected length of stay and improve observed v. expected length of astay ratios

-Appropriate reimbursement. Appropriate MS-DRG and other DRG systems assignment reflective of the resource is consumed.

-VBP, P4P, Bundled payments, ACO preparation. More accurately reflects the quality of care, outcomes and cost of the treating the patients.

-ICD-10. complete and accurate documentation is critical under ICD-10

Opportunity for compliance to collaborate with the CDI team:Bridge CDI,HIM and quality calloboration.