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For decades, provider documentation has served multiple critical functions. It’s the foundation of clinical communication, ensuring that every member of the care team has a clear, complete picture of ...

Clinical documentation is the written record of a patient-physician encounter. Before the advent of electronic health records (EHRs), these encounters were often inadequately documented. While this ...

The underlying challenge in every documentation project is to produce quality documentation on time and within budget. You can do this successfully, provided you understand and use proven document ...

Everything hospital executives need to know about the importance of clinical documentation improvement is summed up in one single fact: CDI fuels correct reimbursement and accurate quality reporting.