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Related Concept Videos

Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Methods of Documentation IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
Methods of Documentation II: POMR01:26

Methods of Documentation II: POMR

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.

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Related Experiment Video

Updated: Jul 3, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
08:13

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

Published on: January 20, 2019

Leading clinical documentation improvement. Three successful HIM-led programs.

Chris Dimick1

  • 1chris.dimick@ahima.org

Journal of AHIMA
|August 5, 2008
PubMed
Summary
This summary is machine-generated.

Clinical documentation improvement (CDI) programs are vital for healthcare. This study highlights three successful CDI programs led by Health Information Management (HIM) departments.

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Last Updated: Jul 3, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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The Participant-Reported Implementation Update and Score (PRIUS): A Novel Method for Capturing Implementation-Related Data Over Time

Published on: February 19, 2021

Area of Science:

  • Healthcare Administration
  • Clinical Informatics

Background:

  • Clinical Documentation Improvement (CDI) programs are essential for accurate medical coding and reimbursement.
  • Leadership models for CDI programs can vary significantly across healthcare organizations.

Purpose of the Study:

  • To examine successful Clinical Documentation Improvement (CDI) programs.
  • To identify the role of Health Information Management (HIM) departments in leading CDI initiatives.

Main Methods:

  • Case study analysis of three distinct healthcare organizations.
  • Review of program structures, workflows, and outcomes within each organization.
  • Interviews with key personnel involved in CDI program management.

Main Results:

  • All three successful CDI programs were led by Health Information Management (HIM) departments.
  • HIM leadership facilitated integration with coding and data analytics.
  • Key success factors included executive support, dedicated resources, and interdepartmental collaboration.

Conclusions:

  • Health Information Management (HIM) departments are well-positioned to lead effective Clinical Documentation Improvement (CDI) programs.
  • Centralizing CDI leadership within HIM can optimize program efficiency and impact.
  • Successful CDI programs require strong leadership, collaboration, and data-driven strategies.