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临床文档改进对澳大利亚医院的重要性。

The importance of clinical documentation improvement for Australian hospitals.

机构信息

3M Health Information Systems, Australia.

Health Information Management Consultant, Australia.

出版信息

Health Inf Manag. 2020 Jan;49(1):69-73. doi: 10.1177/1833358319854185. Epub 2019 Jul 14.

Abstract

Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in "real time" so that it is fit for reporting, analysis and reimbursement. Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment.

摘要

临床文档改进(CDI)是澳大利亚最近一项日益受到关注的举措。其在国际上取得成功的好处包括提高质量和患者安全结果以及增加报销。CDI 的前提很简单:让临床医生参与实时改进医疗记录中的临床文档,使其适合报告、分析和报销。每个国家都有不同的医疗体系,本文重点验证了 CDI 对澳大利亚医疗环境的相关性。

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