Background: Clinical Documentation Improvement programs have been present in adult hospitals for many years. These programs strive to promote clinicians working together with nurse specialists to appropriately depict the care delivered and increase coding accuracy. This collaboration has traditionally been through written and verbal documentation queries that clarify diagnoses based on a patient’s clinical indicators [...]

Background: Malnutrition affects up to 30% of inpatients, but is rarely diagnosed. This leads to under-treatment and poor patient outcomes including: infections, pressure ulcers, and poor wound healing. In the MS-DRG system, malnutrition is considered either a major complication/comorbidity (MCC) or a complication/comorbidity (CC), depending on specificity and severity. Therefore, missed diagnoses significantly impact patient [...]

Background: Neonatal abstinence syndrome (NAS) occurs when an infant is exposed to licit or illicit chemical substances in utero and manifests symptoms of withdrawal from the substance(s) after birth. NAS is a clinical diagnosis, but is generally confirmed with testing of infant urine and/or meconium to identify specific causative substances. Appropriate identification, documentation, and communication [...]