Intellis Vice President of Clinical and Quality Services Allison Clerval, RN BSN CCDS CDIP CRC, provides education on the elements that are included in high-quality documentation. When these elements are missing, the CDS or coder are tasked with clarifying the record via a query. The query process is reviewed with emphasis on maintaining a compliant practice throughout the patient admission through post-discharge review. Elements of compliant practice in the outpatient setting are briefly discussed.
Presented by: Allison Clerval, RN BSN CCDS CDIP CRC, Intellis Vice President