MD Assist-Computer-Assisted Physician Documentation-Transition to ICD-10

DaffyDoc (United States of America)
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  1. coding system
    a system of signals used to represent letters or numbers in transmitting messages
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  2. documentation
    confirmation that some fact or statement is true
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  3. workflow
    progress (or rate of progress) in work being done
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  4. coder
    a person who designs and writes and tests computer programs
    To receive fewer queries from coders and CDI specialists for more information or clarification.
  5. coding
    act of writing in code or cipher
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  6. automate
    operate or make run by machines rather than human action
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  7. template
    a model or standard for making comparisons
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  8. clinical
    relating to or based on direct observation of patients
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  9. real time
    the actual time that it takes a process to occur
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  10. structured
    having a definite and highly organized system
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  11. training program
    a program designed for training in specific skills
    To generate operational and administrative reports to identify persistent documentation gaps
    and develop focused training programs.
  12. real-time
    of or relating to computer systems that update information at the same rate they receive information
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  13. upfront
    frank and honest
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  14. compliant
    disposed to act in accordance with someone's wishes
    To produce more specific ICD-10-compliant clinical documentation in real time.
  15. clarification
    the act of removing solid particles from a liquid
    To receive fewer queries from coders and CDI specialists for more information or clarification.
  16. reimbursement
    compensation paid for damages or money already spent
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  17. physician
    a licensed medical practitioner
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  18. intricacy
    the quality of having elaborately complex detail
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  19. leverage
    the mechanical advantage gained by a machine on a fulcrum
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  20. automated
    operated with minimal human intervention
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  21. specialist
    an expert devoted to one occupation or branch of learning
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  22. healthcare
    the preservation of mental and physical health by preventing or treating illness through services offered by the health profession
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  23. dictate
    a guiding principle
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  24. ambiguity
    unclearness by virtue of having more than one meaning
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  25. operational
    pertaining to a series of actions for achieving a result
    To generate operational and administrative reports to identify persistent documentation gaps
    and develop focused training programs.
  26. dictation
    an authoritative direction or instruction to do something
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  27. transition
    the act of passing from one state or place to the next
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  28. deepen
    make deeper
    To expand and deepen their CDI case coverage.
  29. pertinent
    being of striking appropriateness
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  30. dictated
    determined or decided upon as by an authority
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  31. ensure
    make certain of
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  32. interactive
    capable of influencing each other
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  33. exhaustive
    performed comprehensively and completely
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  34. gap
    an open or empty space in or between things
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  35. appropriately
    in an appropriate manner
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  36. combine
    put or add together
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  37. focused
    brought into sharp clarity
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  38. assisted
    having help; often used as a combining form
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  39. manual
    of or relating to the hands
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  40. identify
    recognize as being
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  41. articulate
    express or state clearly
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  42. expand
    extend in one or more directions
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  43. coverage
    the extent to which something is included or discussed
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  44. document
    a representation of a person's thinking with symbolic marks
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  45. focus
    the concentration of attention or energy on something
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  46. diagnosis
    identifying the nature or cause of some phenomenon
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  47. computer
    a machine for performing calculations automatically
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  48. query
    an instance of questioning
    To receive fewer queries from coders and CDI specialists for more information or clarification.
  49. generate
    bring into existence
    To generate operational and administrative reports to identify persistent documentation gaps
    and develop focused training programs.
  50. code
    a set of rules or principles or laws
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  51. patient
    enduring trying circumstances with even temper
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  52. assist
    give help; be of service
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  53. narrative
    an account that tells the particulars of an act or event
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  54. flexible
    able to bend easily
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  55. reap
    get or derive
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  56. challenging
    requiring full use of your abilities or resources
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  57. tool
    an implement used to perform a task or job
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  58. rely on
    put trust in with confidence
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  59. program
    a series of steps to be carried out
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  60. specific
    stated explicitly or in detail
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  61. inability
    lack of capacity to do something
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  62. complex
    complicated in structure
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  63. summary
    a brief statement that presents the main points
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  64. inadequate
    lacking the requisite qualities or resources to meet a task
    With the transition
    to ICD-10, manual reviews will prove inadequate to ensure that physician documentation is as
    complete and accurate as this new coding system requires.
  65. improvement
    the act of making something better
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  66. capture
    seize as if by hunting, snaring, or trapping
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  67. electronic
    relating to or operating by a controlled current
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  68. initiative
    readiness to embark on bold new ventures
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  69. relevant
    having a bearing on or connection with the subject at issue
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  70. persistent
    stubbornly unyielding
    To generate operational and administrative reports to identify persistent documentation gaps
    and develop focused training programs.
  71. existing
    having being or actuality
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  72. combined
    made or joined or united into one
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  73. system
    a group of independent elements comprising a unified whole
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  74. administrative
    responsible for managing the affairs of a group of people
    To generate operational and administrative reports to identify persistent documentation gaps
    and develop focused training programs.
  75. outcome
    something that results
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  76. structure
    a complex entity made of many parts
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  77. accuracy
    the quality of being near to the true value
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  78. rely
    have confidence or faith in
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  79. data
    a collection of facts from which conclusions may be drawn
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  80. episode
    a happening that is distinctive in a series of events
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  81. keep up
    maintain a required pace or level
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  82. exist
    have a presence
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  83. review
    look at again; examine again
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  84. alert
    warn or arouse to a sense of danger
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  85. allow
    make it possible for something to happen
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  86. accurate
    characterized by perfect conformity to fact or truth
    With the transition
    to ICD-10, manual reviews will prove inadequate to ensure that physician documentation is as
    complete and accurate as this new coding system requires.
  87. provide
    give something useful or necessary to
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  88. entry
    the act of going in
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  89. training
    activity leading to skilled behavior
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  90. fewer
    quantifier meaning a smaller number of
    To receive fewer queries from coders and CDI specialists for more information or clarification.
  91. collect
    gather
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  92. tomorrow
    the day after today
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  93. information
    knowledge acquired through study or experience
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  94. payment
    the act of giving money in exchange for something
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  95. improve
    to make better
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  96. develop
    progress or evolve through a process of natural growth
    To generate operational and administrative reports to identify persistent documentation gaps
    and develop focused training programs.
  97. recorded
    set down or registered in a permanent form especially on film or tape for reproduction
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  98. level
    a relative position or degree of value in a graded group
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  99. limit
    as far as something can go
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  100. preferred
    more desirable than another
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  101. environment
    the totality of surrounding conditions
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  102. prefer
    like better; value more highly
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  103. note
    a brief written record
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  104. challenge
    a call to engage in a contest or fight
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  105. describe
    give a statement representing something
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  106. mode
    how something is done or how it happens
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  107. train
    educate for a future role or function
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  108. today
    on this day as distinct from yesterday or tomorrow
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  109. prepare
    make ready or suitable or equip in advance
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  110. work in
    add by mixing or blending on or attaching
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  111. critical
    of a serious examination and judgment of something
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  112. solution
    a homogeneous mixture of two or more substances
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  113. suggestion
    an idea that is proposed
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  114. technology
    the practical application of science to commerce or industry
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  115. maintain
    keep in a certain state, position, or activity
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  116. create
    bring into existence
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  117. reform
    make changes for improvement to remove abuse and injustices
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  118. federal
    of a government with central and regional authorities
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  119. case
    an occurrence of something
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  120. properly
    in the right manner
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  121. base
    lowest support of a structure
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  122. real
    being or occurring in fact or actuality
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  123. ability
    the quality of having the means or skills to do something
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  124. report
    to give an account or representation of in words
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  125. benefit
    something that aids or promotes well-being
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  126. require
    have need of
    With the transition
    to ICD-10, manual reviews will prove inadequate to ensure that physician documentation is as
    complete and accurate as this new coding system requires.
  127. limited
    subject to restrictions or constraints
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  128. performance
    the act of doing something successfully
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  129. test
    standardized procedure for measuring sensitivity or aptitude
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  130. hospital
    a medical institution where sick or injured people are given medical or surgical care
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  131. understanding
    the condition of someone who knows and comprehends
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  132. based
    having a base
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  133. highly
    to a great degree or extent; favorably or with much respect
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  134. driven
    compelled forcibly by an outside agency
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  135. quality
    an essential and distinguishing attribute of something
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  136. struggle
    strenuous effort
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  137. produce
    bring forth or yield
    To produce more specific ICD-10-compliant clinical documentation in real time.
  138. understand
    know and comprehend the nature or meaning of
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  139. clearly
    without doubt or question
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  140. drive
    operate or control a vehicle
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  141. current
    occurring in or belonging to the present time
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  142. process
    a particular course of action intended to achieve a result
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  143. prove
    establish the validity of something
    With the transition
    to ICD-10, manual reviews will prove inadequate to ensure that physician documentation is as
    complete and accurate as this new coding system requires.
  144. practice
    a customary way of operation or behavior
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  145. record
    anything providing permanent evidence about past events
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  146. content
    satisfied or showing satisfaction with things as they are
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  147. needed
    necessary for relief or supply
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  148. receive
    get something; come into possession of
    To receive fewer queries from coders and CDI specialists for more information or clarification.
  149. rule
    prescribed guide for conduct or action
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  150. complete
    having all necessary qualities
    With the transition
    to ICD-10, manual reviews will prove inadequate to ensure that physician documentation is as
    complete and accurate as this new coding system requires.
  151. learn
    gain knowledge or skills
    To learn interactively how to document relevant diagnoses properly, with no upfront training.
  152. language
    a means of communicating by the use of sounds or symbols
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  153. new
    not of long duration
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  154. move
    change location
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  155. success
    an event that accomplishes its intended purpose
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  156. will
    the capability of conscious choice and decision
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  157. greater
    greater in size or importance or degree
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  158. field
    extensive tract of level open land
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  159. paper
    a material made of cellulose pulp derived mainly from wood or rags or certain grasses
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  160. instead
    in place of, or as an alternative to
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  161. change
    become different in some particular way
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  162. state
    the way something is with respect to its main attributes
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  163. able
    having the necessary means or skill to do something
    CDI specialists will then be able
    to leverage this automated tool to expand their case coverage and focus their work in preparing
    physicians for the transition to ICD-10.
  164. care
    providing treatment for or attending to someone or something
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  165. story
    a record or narrative description of past events
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  166. need
    require or want
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  167. within
    on the inside
    2
    Summary
    Healthcare reform, federal and state quality initiatives, and the move to outcomes-based payments
    are creating a complex new environment within healthcare.
  168. time
    the continuum of experience in which events pass to the past
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  169. keep
    continue a certain state, condition, or activity
    Current CDI programs,
    which rely on manual reviews of patient cases and physician documentation to alert physicians to
    gaps in their documentation, struggle today to keep up with their existing cases.
  170. way
    how something is done or how it happens
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
  171. more
    greater in size or amount or extent or degree
    Highly specific, exhaustive, and clearly recorded patient information will be critical to maintain
    existing levels of reimbursement, ensure the accuracy of performance reports, and reap the
    benefits of this more articulate and flexible coding system.
  172. use
    put into service
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  173. power
    possession of the qualities required to do something
    This paper describes a new system for clinical documentation and clinical documentation improvement
    that leverages the combined power of Clinical Language Understanding (CLU) and CDI technologies to
    provide a real-time, Computer-Assisted Physician Documentation (CAPD™) solution for documenting
    under ICD-9 today and ICD-10 tomorrow.
  174. tell
    narrate or give a detailed account of
    To use narrative dictation—their preferred mode of documentation—instead of structured
    templates and data fields to tell patients’ stories.
  175. however
    in whatever way or manner
    However, the electronic documentation systems needed to collect this information have had limited
    success in clinical practice because of the intricacies of structured data entry workflows and the
    inability of template-driven clinical notes to capture physician narratives.
  176. put
    cause to be in a certain state
    The complex transition to the ICD-10 coding system will put clinical documentation tools and
    processes, and Clinical Documentation Improvement (CDI) programs, to an even greater test.
  177. give
    transfer possession of something concrete or abstract
    The ability to understand the content of a dictated note in real time, combined with CDI rules,
    will allow this system to identify gaps and ambiguities in notes and give physicians pertinent
    and focused suggestions to improve their dictated narratives.
  178. each
    separately for every person or thing
    These changes are challenging the way
    physicians document patient episodes and the way hospitals ensure that physician documentation
    appropriately captures the level of care provided to each patient.
Created on Sun Jul 29 08:50:53 EDT 2012 (updated Sun Jun 08 16:48:33 EDT 2014)

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