AHIMA March 1, 2020
Editor’s Note: This Practice Brief supersedes the November-December 2017 Practice Brief titled “CDI Expanding Beyond the Hospital Walls through Standards.”
The proverbial “apples and oranges” comparison is a well-known and often useful metaphor. While they are both fruit, there are still many differences between the two. When talking about expanding clinical documentation integrity (CDI) programs in light of today’s electronic health record (EHR) environment and efforts to improve information governance, the scope of CDI extends beyond the walls of the hospital to other areas, such as physician practices. As this expansion continues, the apples and oranges metaphor is an apt one for the two types of documentation—inpatient and outpatient—that we encounter. Just as clinical documentation is clinical documentation regardless of...
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