Log in
Log inBook a demo

Conducting the Health Record Review

INTERACTIVE
HC Pro
23 mins

Conducting the Health Record Review

INTERACTIVE
HC Pro
23 mins

Course Overview

This course will focus on the learning needs for the new or beginning Clinical Documentation Improvement (CDI) specialist in a short term acute care setting (hospital). While the healthcare provider can be a physician, advance practice nurse, registered nurse, or physician assistant, for clarity this course will reference the physician as the healthcare provider. Many of these concepts can be applied to other healthcare settings.


Learning Objectives

Upon completion of this online activity, the participant should be able to:

  • Identify whose documentation can be used for coding a health record
  • Discuss the difference in a concurrent review, follow up review, and a back-end review
  • Describe how to prioritize concurrent health record reviews
  • Demonstrate the steps to conduct a health record review

Duration

23 minutes


Accreditation Statements

AHIMA: This program has been approved for _1_ continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA).

American Nurses Credentialing Center (ANCC): HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This educational activity for _0.8_ nursing contact hours is provided by HCPro.

Association of Clinical Documentation Improvement Specialists (ACDIS): This program has been approved for _1_ continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification, offered as a service of the Association of Clinical Documentation Improvement Specialists (ACDIS).