Using CDI to meet federal quality measures.

摘要

CLINICAL DOCUMENTATION IS the foundation of every health record, specifically outlining the reasons for treatment and the quality of care provided to the patient. The lack of consistent and standard clinical content within the health record has heen an ongoing challenge to health information management (HIM) professionals, especially as their organizations attempt to attest to the "meaningful use" EHR Incentive Program. In order to prove to the Centers for Medicare and Medicaid Services (CMS) that an organization is meeting the program's various quality measures, adequate clinical documentation is needed. Some providers have turned to clinical documentation improvement (CDI) programs to strengthen their documents not only for meaningful use, but several other quality measure programs. Quality clinical documentation is needed for a host of federal initiatives, such as ICD-10-CM/PCS and CMS' patient safety initiative.