Organizations that care for pediatric inpatients but whose CDI programs do not currently perform focused quality reviews may be overlooking a practical opportunity to improve Agency for Healthcare Research and Quality (AHRQ) potentially...Read More »
If a tree falls in a forest and no one is around to hear it, does it make a sound?
People have applied this thought experiment to many topics, so why not medical documentation? Beyond capturing primary and secondary diagnoses, what goes into a record can...Read More »
My journey into clinical documentation integrity began long before I ever heard the term “CDI.” In my early nursing roles on the medical-surgical floor, PCU, and travel nursing, I was consistently drawn to process improvement and standardization...Read More »
As if clinically validating sepsis wasn’t complicated enough, adding in the inherent complexity of pediatric health makes reviewing for this diagnosis more akin to jumping hurdles than a walk in the park. Even the international consensus of...Read More »
When I reflect on my first days as a CDI reviewer almost five years ago, I can still vividly remember how overwhelming that transition felt. I came into the role after spending years as an experienced nurse in my previous specialty, confident in...Read More »
Congenital heart defects (CHD) are commonly encountered chronic conditions in pediatric documentation, yet their presence alone does not ensure they are appropriately reported or fully understood within the clinical context of an encounter....Read More »
For many years, malnutrition has stood at the top of the list for CDI efforts. The reasons behind this focus are multifaceted. The diagnosis has long been an audit and denial target in the sights of the Office of Inspector General, which makes it crucial for...Read More »
