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Clinical Documentation | CDI | News, Analysis, Insights

4 Ways to Improve Clinical Document Capture

by Our Thought Leaders 07/30/2012 1 Comment

 Written by David McKanna, product marketing manager at Nuance “Business Week predicted the paperless office in 1975, when it was thought that computer records would completely replace paper.  In the next two decades after that pronouncement, paper use doubled.” This quote is taken from Persistent Paper: The Myth of “Going Paperless” from AMIA which provides a relevant list of reasons why paper is still widely used in healthcare.  Even fully electronic (Stage 7) hospitals still receive
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Medical Transcription & EHRs: Remaining Atop Technology and Industry Changes

by Fred Pennic 07/02/2012 1 Comment

A vital aspect of health care, medical transcription is a multi-billion-dollar industry, which is undergoing significant changes. Medical transcription has been a fundamental and necessary aspect of the healthcare industry for a long time. However, the continuing development of transcription-related technology is changing the way medical transcription works. To adapt and remain efficient, healthcare-affiliated institutions must adopt these new technologies as they come. Medical transcription
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Video: How to Fill Coding Documentation Gaps When Converting to ICD-10

by Fred Pennic 06/11/2012 Leave a Comment

Here is a recent ICD-10 Summit Wrap up video interview with Mary Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, vice president of HIM consulting services at UASI talks about coding documentation gaps and the best ways to fill them in converting to ICD-10. Stanfill provides the following tips on addressing coding documentation gaps: Identifying high risk areas suchas surgical procedures for amputations must be coded as mid, high, or low in order code the case Improve physician/clinician
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Northern Virginia Regional Health Information Organization Inc. Launches Innovative Medication History Service

by Fred Pennic 06/23/2011

 In an emergency department (ED), where patients’ health and safety hang in the balance, every second counts. Now, Inova Alexandria Hospital ED clinicians can quickly access a patient’s prescriptions information, no matter where in the U.S. they were written, enhancing care quality and safety.The April medication history service launch in this busy Washington, D.C. suburb ED marks the first project milestone for the Northern Virginia Regional Health Information Organization (NoVaRHIO). This
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