When it comes to documenting medical information, Clinical Documentation Specialists have to deal with a lot of tricky elements. That’s where ChartWise 2.0’s Clinical Documentation Improvement Program comes in. Here are 6 challenges that CD Specialists face and the solutions that ChartWise 2.0 provides for them.
1) Documentation can be unclear—ChartWise 2.0’s CDI Program has built-in intelligence “expertise guides” that use lab data, medications, and procedures to help identify additional diagnoses that might not have been clear in the doctor’s notes.
2) Doctors’ long response time to queries—When you create an electronic query in ChartWise 2.0, the application automatically sends all attendees an email. So, the doctor simply logs in, clicks on his responses, and the query is completed.
3) Queries don’t always meet AHIMA rules—This CDI program features AHIMA-conformant electronic queries to ensure compliance and consistency.
4) Major risk factors, like Congestive Heart Failure or diabetes, aren’t always recorded—ChartWise 2.0 automatically triggers additional diagnoses from the lab data, medications, and existing procedures and diagnoses. That way, you can discover any issues that might have gone unnoticed.
5) Reports don’t always show the value of your CDI Program—They can be prepared by hand and with old data, which doesn’t help to support your program. ChartWise 2.0’s on-demand reporting tools includes program impact, case mix index, complication rates, response rates, and more—all in the click of button—which helps support it and gain visibility in your medical facility.
6) Charts and admissions can be tedious to review—Thankfully, ChartWise 2.0’s CDI program allows for easy uploads of patient data, query tracking, response capture, and email notifications to doctors—making the whole process much more efficient.