Clinical Documentation Improvement

What is Clinical Documentation Improvement?

Clinical documentation improvement focuses on the overall quality of care in healthcare organizations. CDI programs play a vital role for patient care by reporting diagnoses and procedures, sharing data with caregivers and boosting claims processing. Hospitals with effective CDI programs ensure that documentation reflects severity of illness and complexity of care. The result? Improved coding specificity, better case mix index (CMI) and enhanced reimbursement.

The ultimate CDI solution

“My CDS need to know which case is the most important case to look at right now…”

We can tell her, based on your criteria — LOS over GMLOS; no CC/MCC; low SOI/ROM; no queries; alternate principal diagnoses DRG’s; missing POA; a particular diagnosis or ICD-10 codes — or some combination… we have it all!

“The LOS is 3 days more than the GMLOS, there are no CC/MCC and SOI/ROM is < 2 — I want a supervisor to see this case”… consider it done!  Need we say more?
Many CDS aren’t coders by training, and many coders take issue with this — but nCode helps CDS get to the correct codes without knowing how to use the logic tree or the codebooks. You’ve never seen anything like this.

And yes, we have coding clinic, coding advice, codebooks and the encoder built in too!

A fully customizable query workflow is ready for you to integrate into your workflow all while ensuring a compliant query is generated. Have as many Query forms as you wish, and design them as you like… nice, right? Oh, and they won’t disappear when we upgrade your software — promise.
Sticky notes don’t work for software — but R1 NOTES do.  Leave a note for yourself, the coder, a physician advisor and your supervisor and have it live with the encounter. Keep it simple — simple is better.

NOTES can be both public and private, so you can share them with other teams, or just your team.

Capture query impact with ease by using simple, integrated tools to compare the original DRG to the final — and it’s reportable as well.

Don't Be Shy

Drop us a line anytime.  One of our team members will respond to you as soon as possible so you can start reaping the benefits of working with the RecordsOne team!