ABOUT

Clinical Documentation Improvement is an integral part in the health care industry. This is the best  approach to help the hospital for reimbursement by reflecting the true severity  of the patient's condition as well as assist the medical practitioners to document accurate diagnosis to provide high quality care.  Completeness in documentation is necessary to conform with quality measures.  As a clinical documentation specialist, your role is to translate the physicians' language to coding language.  As the saying goes, "if it was not documented, it was not done".     

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Nowadays, relationships between clinical documentation and coding processes are vital to the revenue cycle within medical facilities, to all healthcare providers, and, more importantly to all the patients.

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Clinical Documentation Improvement professionals include people with various clinical backgrounds and medical knowledge who can better understand and translate the documentation that is available in the chart. Clinical Documentation Specialists are well rounded individual who is able to work with the coders as well able to explain to the medical practitioners for the need of a better way to document. These include nurses, foreign medical graduates and coders. Being a Clinical Documentation Specialists, you should be able to have a better understanding of required documentation, coding assignment and guidelines and assist with quality reporting. Clinical Documentation Specialists needs to be certified by either of the 2 organizations:  Association of Clinical Documentation Improvement Specialist or AHIMA. 

 

We are Clinical Documentation Specialists who have plenty of experiences in the field. We are Certified Clinical Documentation specialists who will be able to impart to you our knowledge, expertise and experiences for you to be successful.