Legacy increases documentation support

Legacy Health has increased its Clinical Documentation Improvement staff by 188% in order to better support the transition to ICD-10 documentation terms and standards.

What is a Clinical Documentation Improvement specialist?

Clinical Documentation Improvement (CDI) specialists review patient medical records and assess whether all conditions and treatments are documented in specific diagnostic terms. The goal is to paint an accurate picture of the severity of a patient’s illnesses and risk of mortality.

How do CDI specialists help providers?

  • They respond real-time to provider inquiries
  • They review the EHR while the patient is in-house to assure documentation reflects:
    • quality of patient care
    • continuity of care among providers
    • diagnosis and procedure specificity
    • clarification of conflicting or missing information
  • They alert providers when documentation needs clarification
  • They attend provider meetings to give feedback and education on changes in documentation requirements
  • They train new physicians/residents and other providers about documentation needs

Resources

Have a question? Contact Linda Haynes, CDI manager.

For more information on ICD-10 resources offered by Legacy Health, visit the MyLegacy intranet page (Legacy login required). Once on the MyLegacy homepage, type "ICD-10 tips" in the "Search" box and you'll be directed to the ICD-10 Specialty Presentations, Tip Cards and Queries page.