Background: Accurate and timely documentation is essential for patient care, as well as the appropriate reflection of patient complexity and severity of illness. Most hospitals utilize a traditional retrospective or contemporaneous physician-query strategy to ensure documentation accurately impacts performance data, reputation/ranking, and reimbursement.  Purpose: Here, we highlight three unique, hospitalist-driven interventions to support accurate documentation [...]

Background: Accurate clinical documentation is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. However, since coding rules and terminology differ from common clinical language, there is a risk that the clinical reality will get lost in translation. This is where clinical documentation improvement (CDI) programs come [...]

Background: The Vizient Quality and Accountability scorecard is a tool that measures academic medical centers (AMCs) clinical performance, focusing on quality and safety while targeting specific opportunities for improvement. The Vizient quality domains include Mortality, Efficiency, Effectiveness, Equity, Patient Experience, and Patient safety. In an academic setting, the frontline healthcare providers are resident physicians. As [...]

Background: Accurate documentation of the patient’s diagnoses helps to reflect the severity of illness which has several downstream impacts: clinical outcomes data, risk stratification, hospital quality metrics data such as readmission and mortality index, hospital reimbursement. For this reason, our health system has various ongoing initiatives on clinical documentation to improve the specification of certain [...]