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Mark your calendar for AHDI’s 2016 Healthcare Documentation Integrity Conference, August 4-6, in downtown Milwaukee, WI. Visit www.ahdionline.org/ACE for more information.
Friday, August 7 • 4:45pm - 5:45pm
Collaborating for Quality: How Healthcare Documentation Specialists and Clinical Documentation Improvement Specialists Can Work Together for Content Improvement

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As healthcare organizations work toward ICD-10 preparedness, they are also adopting and adapting to new technologies and workflows for documentation capture. Use of medical transcriptionists (now known as healthcare documentation specialists) to type and edit dictation has been reduced in favor of speech recognition and direct EHR data entry by physicians, but the impact to documentation quality has not necessarily been positive.

Clinical documentation improvement (CDI) professionals are under pressure to ensure physicians will provide the necessary documentation to support ICD-10 coding, and are looking for other ways to leverage or extend CDI activities. HDSs are the ideal partner in working with CDIs to improve documentation capture tools and processes so that physicians are adequately supported, documentation quality is improved, and ICD-10 coding is successful.

In this session, the presenters will use examples of common issues discovered by CDIs when evaluating documentation for ICD-10 preparedness. They will suggest how to enlist HDSs to determine how documentation capture tools and processes can be improved to resolve each scenario. Utilizing both CDIs and HDSs, organizations can build a strong documentation quality improvement cycle in which common CDI queries can be reduced or eliminated over time.

Learning Objectives

  1. Describe the roles and goals of both healthcare documentation specialists (HDS) and clinical documentation improvement specialists (CDI) and how they fit into the documentation capture workflow within healthcare organizations
  2. Highlight common documentation issues discovered by CDI as they prepare for ICD-10 implementation
  3. Describe various documentation capture scenarios that may contribute to poor content quality
  4. Illustrate how common documentation issues can be addressed by HDS through collaboration with CDI


avatar for Susan E. Belley, M.Ed., RHIA, CPHQ

Susan E. Belley, M.Ed., RHIA, CPHQ

Manager, Clinical Content Development, 3M Health Information Systems
Susan Belley is the Manager of Clinical Content Development for 3M Health Information Systems Consulting Services and is responsible for oversight of clinical content and new service/product development. She is a graduate of The Ohio State University with a degree in health information... Read More →
avatar for Jill Devrick, MPA

Jill Devrick, MPA

Product Solutions Advisor, 3M Health Information Systems
Jill Devrick is a Product Solutions Advisor for 3M Health Information Systems, specializing in electronic healthcare documentation software solutions for 20 years. She is currently product manager for 3M’s ChartScript and VoiceScript software. Jill earned a Master’s degree in... Read More →

Friday August 7, 2015 4:45pm - 5:45pm EDT
Plaza Ballroom B/C

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