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Informatics, Using Data

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Submitted By catbird05
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Using the Data/Information/Knowledge/Wisdom Continuum
Cathy L. Cooper
Walden University
NURS 6051N-13 Transforming Nursing and Healthcare Through Information Technology
Instructor: Dr. Wagner
March 27, 2016

Using the Data/Information/Knowledge/Wisdom Continuum
Introduction
Many organizations now have clinical documentation improvement programs (CDIs) designed to help an organization accurately reflect the quality of patient care, prove healthcare services, and make accurate reports of diagnosis and procedures (Cassano, 2014). A Clinical Documentation Specialist (CDS) is a registered nurse who manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, risk of mortality, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness (Cassano, 2014). Health Information Management (HIM) professionals advocate for a strong commitment to accurate and timely clinical documentation as hospital initiatives push forward with programs such as ICD-10-CM/PCS implementation, Accountable Care Organizations reimbursement models, Fraud and Abuse compliance programs, and implementation of electronic health records (EHRs) (AMIHA, 2010). HIM professionals also impact CDI programs by providing education regarding compliant documentation to physicians, something that is not taught in medical school.
Successful CDI programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality report cards, physician report cards, reimbursement, public health…...

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