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Related Concept Videos

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...
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:
Nursing Clinical Information System01:27

Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Formulating and Validating Nursing Diagnosis II01:25

Formulating and Validating Nursing Diagnosis II

Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, health promotion or wellness, and syndrome. The anatomy of a nursing diagnosis includes three components: problem statement or diagnostic label, defining characteristics, and related factors.
Risk nursing diagnoses represent clinical judgments of an individual, family, or community more vulnerable to developing the health problem than others...
Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Data Validation01:03

Data Validation

Data validation is an essential part of a comprehensive assessment. Validation is confirming or verifying and opening the door to gathering more assessment data as it clarifies vague or unclear data. The process of checking and verifying the collected information is called data validation. The primary purpose of data validation is to ensure data is as free from error, bias, and misinterpretation as possible.
Nursing assessment guides are generally based on holistic models rather than medical...

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Related Experiment Video

Updated: May 9, 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

Validating competence: a new credential for clinical documentation improvement practitioners.

Jessica Ryan1, Karen Patena, Wallace Judd

  • 1University of Chicago Medical Center, Chicago, IL, USA.

Perspectives in Health Information Management
|July 12, 2013
PubMed
Summary
This summary is machine-generated.

The Commission on Certification for Health Informatics and Information Management (CCHIIM) established professional standards for clinical documentation improvement (CDI) practitioners. This ensures certified CDI professionals possess essential skills for healthcare quality, coding, and reimbursement.

Keywords:
Commission on Certification for Health Informatics and Information Management (CCHIIM)clinical documentation improvement (CDI)credentialdocumentationexamhealth information management (HIM) job rolesjob analysissurvey

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Area of Science:

  • Health Informatics
  • Healthcare Management
  • Professional Credentialing

Background:

  • The Health Information Management (HIM) field is evolving, necessitating the identification of specialized roles.
  • Emerging HIM roles require defined proficiency levels and professional standards.

Purpose of the Study:

  • To define the tasks, responsibilities, and knowledge base for the clinical documentation improvement (CDI) practitioner role.
  • To establish a foundation for the Clinical Documentation Improvement Practitioner (CDIP) credential.

Main Methods:

  • Employed job analysis methodology with subject-matter experts (SMEs).
  • Surveyed a random sample of 4,923 CDI professionals on job tasks and required knowledge.
  • Developed a weighted blueprint of the CDI practitioner role based on survey data.

Main Results:

  • Identified six major domains comprising the CDI practitioner role.
  • The blueprint served as the basis for the CDIP credential development.
  • Validated the essential competencies for effective CDI practice.

Conclusions:

  • Healthcare organizations can rely on certified CDIPs to demonstrate expertise.
  • Certified practitioners exhibit proficiency in clinical care, treatment, coding guidelines, and reimbursement.
  • The CDIP credential signifies a codified level of proficiency in clinical documentation improvement.