Clinical Documentation Specialist

As the Clinical Documentation Specialist (CDS), you need to ensure that all patient medical documentation is accurate, complete, and maintained in accordance with hospital policies and legal regulations. Quality control assurance also rests on your shoulders, while growing caseloads make it imperative that your CDI program runs as efficiently as possible.

Click the challenges below to learn how ChartWise can address your needs.


Our built-in intelligent expertise guides physician and CDS toward a complete diagnostic picture, using lab data, medications and procedures to help find complications and additional diagnoses that have not been specified completely in the doctor’s notes. System-generated suggestions help identify possible diagnoses to query, resulting in more complete documentation.


Create an electronic query in ChartWise 2.0, and the application will send the attending an email notification. The doctor logs in, and a few clicks later the response is recorded and the query is completed. If you prefer, you can still print the query and leave it for the doctor, entering the reply to capture the information. Or, a number of options are available to put the query into your EMR for the physician to review.


Avoid the risk of leading questions with AHIMA-conformant electronic queries that help ensure compliance and consistency across your CDI program. Saved in PDF format, queries are easily retrievable and auditable for both your internal QA program and outside auditors.


Suggestions for additional diagnoses are automatically triggered from the lab data, medications, existing diagnoses and procedures, helping you find complications that might otherwise have been overlooked and gone uncoded.


Extensive on-demand reporting tools provide the documentation to support your program and gain visibility in your institution. Program impact, case mix index, response rates, complication rates, query reasons, and APR severity and mortality are among the included reports— available with a click of the button. 


ChartWise can help you review more admissions by making the process more efficient. With easy uploads of your patient data, query tracking, response capture, and email notification to physicians, there will be no more chasing down doctors, no looking for paper queries or sticky notes, and no forgotten charts.

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