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Practice Toolkit: Medical Record Completion

Author: Hirsch, Ronald

Source: Journal of AHIMA

Publication Date: January 2006


Medical record completion compliance has always been a problem at Sherman Hospital, a medium-sized community hospital in Elgin, IL. The number of incomplete charts often exceeded the standard set by the Joint Commission on Accreditation of Healthcare Organizations, risking a type I violation.....

Documentation Improvement Initiative at Maimonides Medical Center, Brooklyn, NY

Author: Rivera, Madeline; Zusman, Irina; Kogan, Susanna; Sichalov, Nadia; Spector, Michelle

Source: AHIMA Convention

Publication Date: October 21, 2005


Summary


Maimonides Medical Center (MMC) in Brooklyn, NY, implemented a successful documentation improvement program in 2001. Under the auspices of the Case Management Department, documentation specialists, who are credentialed HIM professionals (RHIA, CCS), perform concurrent and....

Clinical Documentation Improvement Program Strategies

Author: Mills, Mary

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction
What Is CDIP?

Aclinical documentation improvement program (CDIP) is a program focused on improving clinical documentation on a concurrent basis where a coder or documentation specialist, such as a nurse, reviews the medical record and consults with physicians regarding....

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