Dublin, March 20, 2025 (GLOBE NEWSWIRE) — The “Improving CDI Programs and Alternative Methods and Solutions for Documenting a Clinical Encounter” webinar has been added to ResearchAndMarkets.com’s offering.
Learn best practices for Clinical Documentation Integrity, identify documentation gaps, and enhance physician communication skills
Clinical Documentation Integrity programs, formally known as Clinical Documentation Improvement programs have existed since 2008 with the advent of the MS-DRG coding and billing system. The need for complete and accurate documentation has evolved to today where payers are expecting to see an accurate and complete account of patient care, incorporating the telling and describing of the patient story and the establishment of medical necessity.
CDI processes have not evolved to meet the changing needs and requirements of physician documentation. By attending this course, attendees will learn how to define best practice standards and principles of documentation, be able to identify true insufficiencies in documentation and even more importantly how to address with the physician.
Attendees will become familiar with the critical nature of the physician’s clinical reasoning and clinical judgement, be able to incorporate these elements into the chart review process, recognize documentation insufficiencies that detract from a complete assessment and plan, and converse with physicians to address and prevent clinical validation denials. Attendees will be able to review a record efficiently in 5 minutes and hone in areas of documentation to address, helping physicians achieve true physician documentation excellence with proactive preemptive denial avoidance documentation.
Learning Objectives
- You will be able to define standards and best practices of physician documentation.
- You will be able to describe common documentation insufficiencies that contribute to medical necessity and clinical validation denials as well as level of care and DRG downgrades.
- You will be able to discuss with the physician how to strengthen the documentation and meet the best practice standards of documentation efficiently and effectively.
- You will be able to identify documentation insufficiencies contributing to denials using real case studies and learn how to address and communicate with physicians.
Key Topics Covered:
Define the Standards of Documentation and Structural Framework That All Providers Must Follow
- Current Standards of Documentation That Physicians Must Follow
- How Should Physicians Operationalize and Apply These Best Practice Standards
- What Are the Key Elements of Documentation
- How to Reinforce to Physicians the Key Elements of Documentation
Common Documentation Deficiencies Contributing to Payer Medical Necessity Andclinical Validation Denials
- What Are the Typical Documentation Deficiencies and Insufficiencies
- How to Identify and Spot These Documentation Insufficiencies
- How to Develop a Strategy to Address These Documentation Insufficiencies With Physicians
- Learn How to Work With Partner and Collaborate With Utilization Review and Case Management
How to Conduct a Thorough Inpatient Medical Record in Five Minutes
- What Are the Key Parts of the Record to Review
- Put All the Pieces of the Record Together Holistically
- Follow the Thought Processes of the Physician as Part of the Chart Review Process
- Developing Provisional Diagnoses as Part of the Chart Review Process
Clinical Reasoning and Judgment, How Does It Factor Into the Record Review Process
- Define Clinical Reasoning and Clinical Judgment From a Physician Perspective
- Align the Physician’s Clinical Judgment and Clinical Reasoning With the Physician’s Documentation to Identify Inefficiencies
- What Role Does Physician’s Lack of Documentation Contribute to Clinical Validation Denials
- How to Address Insufficiencies in Physician Documentation
For more information about this webinar visit https://www.researchandmarkets.com/r/ew7t9k
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