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Abstract Number: 397
IMPLEMENTING A STANDARDIZED DIAGNOSIS LIST TO ENHANCE CLINICAL DOCUMENTATION ACCURACY
SHM Converge 2024
Background: Clinical documentation is essential for adequate representation of patient quality care metrics and accurate diagnosis capture but rarely taught in graduate medical education. Inaccurate capture of diagnoses leads to clinical documentation integrity (CDI) queries, which increase workload on busy providers. Implementation of a standardized note template for our resident physicians previously resulted in an [...]
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