Clinical Documentation Improvement

Spot gaps in clinical notes, write clear queries to clinicians, and see why unsupported codes fail audits.

Advanced
About 18 hours of study
15 CEU hours
Certificate on completion

Taught by Tunde Adebayo · 1 learner enrolled

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What is inside

3 modules, 8 lessons, 3h 6m of material.

Module 1 What a good record contains 2 lessons · 34 min

The gap between what happened and what was written.
- Documentation gaps you will meet weekly Preview Video 18 min
- Specificity: "diabetes" is not a diagnosis Video 16 min
Module 2 Writing a query 3 lessons · 1h 5m

Asking a clinician without leading them to an answer.
- The anatomy of a compliant query Video 21 min
- Leading questions and how to avoid them Reading 14 min
- Write three queries Exercise 30 min
Module 3 Audit and consequences 3 lessons · 1h 27m

How unsupported codes are found and what follows.
- How an external audit reads your record Video 17 min
- Audit an admission end to end Lab 45 min
- Final assessment Quiz 25 min

The lesson times add up to 3h 6m of material, while the course is listed as about 18 hours. The larger figure includes the exercises, reading and practice you do yourself, which is where most of the learning happens.

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