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: Risk adjustment indices are frequently used for hospital billing and reimbursements in the United States. Severity of illness (SOI) and risk of mortality (ROM) are two risk adjustment indices used in determining the APR-DRG, a classification system commonly used by insurers to determine hospital reimbursements. Recently, many health systems implemented AI-powered clinical documentation assistants [...]