STM publisher Elsevier has announced the launch of the Elsevier Clinical Documentation Improvement (CDI) Reference App for Apple and Android phones and tablets. The free mobile app was created using ICD-10 coding requirements and developed specifically for physicians and clinical documentation specialists to help improve clinical documentation within the healthcare record. Using Elsevier original content, the Elsevier CDI Reference app is now available for free download via iTunes and Google Play.
The app enables clinicians to quickly and easily find the exact clinical terms or phrases to accurately describe a specific patient condition. Additionally, it will help demonstrate medical necessity for services, justify admission and treatment, and accurately reflect the severity of illness based on the patient's presentation. This allows the physician to document conditions correctly and creates a seamless handoff between the physician and the coder for payment.
The app focuses on 45 conditions that have the most compliance risk, changes to documentation requirements, payment or audit implications, or that generate the most queries for specification from coding staff. Examples of conditions include, Chest Pain and Angina, Dementia, Heart Failure, Kidney Disease, Myocardial Infarction, OB, Perinatal Care, Pneumonia, Sepsis and SIRS, Spinal Disorders, Syncope and Collapse, and Venous Thromboembolism.
Key documentation elements that are provided under each condition include: Acuity; Designation of type of condition; Etiolog; Associated conditions and manifestations; Clinical indicators; Staging; Treatments or interventions; and Information unique to neonates or pediatric patients, if appropriate
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