Carr Kimberly Janet
HRS, Baltimore, Md., USA.
Healthc Financ Manage. 2013 Jun;67(6):118-22.
Hospitals can improve clinical documentation under ICD-10 by implementing three strategies: Bring clinical documentation improvement (CDI) specialists and coders together for daily or weekly communications to improve documentation quality, processes, and outcomes. Encourage CDI specialists to engage in direct, one-on-one conversations with physicians or generate queries, whether paper or EHR-based, to clarify missing or unclear documentation to promote better overall clinical documentation outcomes. Assess ICD-10 hot spots for documentation gaps to mitigate risk of lost revenue under ICD-10.
医院可以通过实施三种策略来改进 ICD - 10 下的临床文档：让临床文档改进（CDI）专家和编码员进行每日或每周沟通，以提高文档质量、流程和结果。鼓励 CDI 专家与医生进行直接的一对一交流或提出疑问（无论是纸质的还是基于电子健康记录的），以澄清缺失或不清楚的文档，从而促进更好的整体临床文档结果。评估 ICD - 10 文档差距的热点问题，以降低 ICD - 10 下收入损失的风险。
