Documentation integrity means completeness, accuracy, and transparency. Without accurate and credible clinical documentation, we have little chance of understanding how care delivery impacts health. While providers are responsible for establishing and supporting a diagnosis, CDI and Coding professionals are responsible for ensuring that the health record reflects the patient’s clinical scenario and is coded accurately. Experts have difficulty agreeing on definitive criteria for common conditions. How do we identify expected variation from unlikely deviation? Even more complex, how do we recognize when diagnostic plausibility is there, and the supporting documentation is ambiguous?
May 6, 2019
CEU: 1.0 – Clinical Data Management
Beth Wolf, MD, CPC, CCDS
Dr. Beth Wolf has more than ten years of experience in palliative medicine and health information management. For the past six years she has worked as the Medical Director for Health Information Management with Roper St Francis, where she applies her expertise in clinical documentation and serves as the primary liaison to the Medical Staff on coding and documentation issues.