Background: Clinical documentation integrity (CDI), a process by which documentation is optimized to be both congruent with Centers for Medicare and Medicaid (CMS) terminology and reflect patient severity of illness, is widely used in healthcare to ensure appropriate coding for hospital reimbursement and improve accuracy of research and quality outcomes. CDI optimization is often performed [...]

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 [...]

Background: Diagnose and treat. That is the role of the physician. But the practice of medicine in recent years has been beaten hollow; its patient mission eclipsed by unwieldy technology and its practitioners so inundated with documentation and data entry, resulting in disengaged, frustrated, and burned out clinicians. The hospitalist has access to the entirety [...]

Background: Accurate clinical documentation is essential for capturing patient severity of illness (SOI) and risk of mortality (ROM). These metrics directly influence hospital quality reporting, including rankings like Vizient and metrics such as Observed-to-Expected Mortality (O:E) ratios. Traditional documentation methods rely heavily on manual input, which in busy clinical practices, results in underrepresented patient risk [...]