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Business Unit: Results

The Next Step Starts Outside Your Comfort Zone 

A Call to Growth for CDI Professionals Ready for More  Careers in Clinical Documentation Integrity rarely follow a straight line. Most of us arrive here from somewhere else. Many of us come from bedside nursing, coding, quality, or case management, drawn in by curiosity, challenge, and a desire to make a meaningful impact. But once we settle into the role, it’s easy to […]

It Takes a Village: Capturing the True Clinical Journey

Every patient encounter tells a story. But no single person, note, or department can tell it alone. The true clinical journey of a patient along with their severity of illness and risk of mortality is shaped over time, through countless decisions, assessments, and moments of care. Capturing that journey accurately requires collaboration across the entire […]

Clinical Accuracy Starts Here: How to Review an Inpatient Chart Like a CDS

Clinical accuracy is the starting point for everything we do in CDI. Before queries. Before DRG optimization. Before quality metrics. If the clinical picture isn’t solid, nothing else holds up. For a Clinical Documentation Specialist (CDS), reviewing an inpatient chart isn’t about hunting for diagnoses or checking boxes. It’s about understanding the patient’s story, what […]

Maternal Documentation Gaps with the Highest Financial Impact (Article 3 of 5)

While newborn records account for the highest volume of missed opportunities, maternal documentation gaps tend to have a greater per-case financial impact. Across reviews, three maternal conditions consistently surfaced as high‑impact misses: Postpartum Hemorrhage (PPH) Estimated blood loss, uterotonic use, and clinical concern were frequently documented—without a definitive diagnosis or severity classification. When PPH is […]

The Newborn Diagnoses That Quietly Drive Revenue Loss (Article 2 of 5)

When organizations consider documentation improvement, new records are rarely the first place they look. Yet across all assessments reviewed, newborn DRGs accounted for the largest share of missed opportunities. The reason is deceptively simple: newborn diagnoses are often observed but not documented in a billable way. The Most Commonly Missed Newborn Diagnoses Across facilities, the […]

The OB/Newborn CDI Series

The Hidden Revenue in OB/Newborn Documentation: What Hundreds of Reviews Reveal Obstetrics and newborn services are rarely considered meaningful drivers of revenue growth. For many health systems, OB is categorized as high-volume, low-margin. A service line where documentation improvement is expected to yield incremental, not transformational, impact. That assumption does not hold up under scrutiny. […]

Clinical Validation vs. Coding: Why CDI Must Step In

A practical framework for getting AKI and sepsis right—every time Executive SummaryClinical validation and coding are complementary, but not interchangeable. CDI must ensure that diagnoses are clinically supported (with objective, consistent evidence), not merely codable. High‑impact areas such as AKI and sepsis benefit most from a structured approach to indicators, terminology, and CDI queries.  1) […]

CDI’s Role in Reducing Clinical Variation

Clinical variation has long been recognized as one of the most persistent challenges in healthcare. Two patients with the same diagnosis, admitted to the same hospital, can experience vastly different care pathways, lengths of stay, or outcomes depending on the provider. While some variation is clinically appropriate—rooted in patient complexity or comorbidities—much of it stems […]