Solutions / CDI – Clinical Documentation Implementation / Improvement

1. Clinical Documentation Integrity and Quality – Validate and Verify that Present on Admission (POA) Indicators are Clearly Documented.
2. Chart Review (Concurrent, Pre Bill, Retrospective) – Review Clinical Issues to Identify Additional Diagnoses that impact Severity of Illness (SOI) and Risk of Mortality (ROM).
3. Queries – Formulate and Distribute Physician Documentation Clarification Queries that meet Coding Guidelines and Compliance Standards.
4. Physician Education – Creates, monitors and tracks verbal and written queries, responses and their impact; producing reports as required Identifies documentation trends, and areas of opportunity for physician education regarding documentation
5. Conduct Data and Root Cause Analysis – Provide Expert Analysis of the Medical Documentation for Signs, Symptoms and Clinical Indicators, that Identifies Primary, Secondary Diagnoses, Complications and Co-Morbidities