The future of clinical documentation improvement (CDI) will require expanding the reach of CDI programs into new areas of expertise because the traditional realms of CDI work are increasingly becoming automated. CDI-based research and analytics can serve as a means for demonstrating continued value to an institution. We present four studies as examples of these efforts. We explored the use of claims data to determine whether a clinical condition meets the criteria for a secondary diagnosis and to evaluate whether a clinical problem should be elevated to the status of a comorbid or complicating condition. We demonstrated a way in which CDI professionals can evaluate the impacts of changes in clinical definitions, and we explored how CDI can work with other institutional programs to decrease length of stay. We believe that these models may serve as a springboard within institutions and among the larger CDI community to make research and analytics a foundation of future CDI activities.
Download full-text PDF |
Source |
---|---|
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341414 | PMC |
Ann Transl Med
December 2024
Division of Advanced Gastrointestinal and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, USA.
Background: Addressing language barriers through accurate interpretation is crucial for providing quality care and establishing trust. While the ability of artificial intelligence (AI) to translate medical documentation has been studied, its role for patient-provider communication is less explored. This review evaluates AI's effectiveness in clinical translation by assessing accuracy, usability, satisfaction, and feedback on its use.
View Article and Find Full Text PDFMol Genet Metab Rep
March 2025
Hayward Genetics Center, Dept of Pediatrics, Tulane University Medical School, New Orleans, LA, USA.
Objective: To provide insights and strategies for pegvaliase management in challenging cases with phenylketonuria (PKU) based on the first 5 years of experience with pegvaliase in real-world clinical practice.
Methods: Twelve PKU experts gathered during a one-day, in-person meeting to discuss clinical cases illustrating important lessons from their experiences treating patients with pegvaliase in real-world clinical practice. Challenges with pegvaliase experienced prior to and during treatment and corresponding strategies to overcome them were discussed.
Cureus
December 2024
Department of Psychiatry, Texas Tech University Health Sciences Center, Odessa, USA.
Schizophrenia is a chronic psychiatric disorder with a complex etiology involving genetic, neurobiological, and environmental factors. Many individuals with schizophrenia experience treatment resistance despite advances in pharmacologic and non-pharmacologic interventions. Immune dysregulation, characterized by altered cytokine levels, immune-related gene expression, and neuroinflammation, plays a critical role in schizophrenia's pathogenesis.
View Article and Find Full Text PDFCureus
December 2024
General Surgery, Port Sudan Teaching Hospital, Port Sudan, SDN.
Background Thorough and standardized documentation of operative notes is essential for effective communication, patient safety, legal protection, and the continuity of care. However, in many hospitals in Sudan, surgeons often use non-standardized methods, resulting in inconsistent and incomplete records. This study evaluates the quality of operative notes at the Port Sudan Teaching Hospital using the Royal College of Surgeons of England (RCSEng) guidelines, aiming to improve compliance and documentation practices.
View Article and Find Full Text PDFCureus
December 2024
General Surgery, Bashair Teaching Hospital, Khartoum, SDN.
Aim The aim is to audit the documentation process for trauma patients presenting to the surgical trauma department and to implement the WHO Standardized Emergency Unit Form: Trauma at Bashair Teaching Hospital in Khartoum, Sudan, in 2022. Methodology The audit was commenced by reviewing the documentation method for trauma patients. There was no standardized form in use.
View Article and Find Full Text PDFEnter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!