Clinical Documentation Essentials for the Hospital Provider

Introduction

Take This Course

Pathway to the CCDS credential!
This library of 17 courses provides hospital-based physicians with a thorough grounding in the basics of compliant clinical documentation. Learners will be able to describe how complete and accurate documentation ensures an accurate depiction of a patient’s severity of illness. After completing all courses in the library, learners will have the opportunity to take a final examination and earn a certificate of documentation integrity along with CME and CCDS credits.

Each course in this library is written by physicians, for physicians, and includes case examples to reinforce its concepts. Nine clinical courses cover definitions of approximately 30 diagnoses from evidence-based literature, incorporating specific terminology usage to capture proper severity of illness. Each course is short, averaging 10–12 minutes, and is responsive to mobile devices—specifically designed to be reviewed on the go by busy providers.

Objectives

At the end of this session, learners will be able to:

Explain the importance of accurate documentation for quality and reimbursement purposes
Identify documentation needs for common diagnoses throughout the major body systems
Describe how complete and accurate documentation assists with compliance and determining the medical necessity of admissions
Define common diagnostic terms needed for accurate coding
Describe the basics of coding, hospital reimbursement, and audit and regulatory initiatives

Main theme

Part 1: (Online interactive)
- An online interactive course for 5 days [3 hours per day].
- Learners will get a Protected version of the PowerPoint presentation.
- Learners should attend the course live and interact with the speaker
- The recording will be available for 21 days
- Exam Preparation CCDS - Level 1
- Assisting with Exam intake for CCDS - Level 1
Part 2: (Recorded - Self-based)
The training includes five modules devoted to key concepts and responsibilities of CDI specialists, four modules devoted to clinical conditions that every CDI specialist must master, and one module devoted to core ACDIS guidelines, including the ACDIS Code of Ethics and the AHIMA/ACDIS Guide to Compliant Query Practice.
Course List
Course Introduction
Diagnosis Related Grouping
CDI and Its Importance
Clinical Terms vs. Coding-Based Language: Understanding the Difference Between Clinical Medical Terminology and Coding Terminology
Coding Primer
ICD-10
Patient Status: Inpatient vs. Observation
Recovery Auditors
Common Documentation Needs for Diagnoses of the Circulatory System I
Common Documentation Needs for Diagnoses of the Circulatory System II
Common Documentation Needs for Diseases of the Endocrine System and Skin
Common Documentation Needs for Diagnoses of the Gastrointestinal System
Common Documentation Needs for Diagnoses Related to Injuries and Medication Reactions
Common Documentation Needs for Diagnoses of the Nervous System
Common Documentation Needs Related to Renal Function
Common Documentation Needs for Diseases of the Respiratory System
Common Documentation Needs Related to Systemic Infection and Shock

Each course is 10–12 minutes long, designed to be reviewed by the busy hospital provider.
The entire program takes about four hours to complete, including the one-hour final exam.

VAT Included
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