Question

A form of clinical decision support that guides a user in appropriate documentation is which of the following?

1) Clinical pathway
2) Clinical decision support system
3) Clinical practice guidelines
4) Clinical documentation improvement

Answer 1

The correct answer is Clinical documentation improvement (CDI), which guides a user in appropriate documentation by improving the accuracy and completeness of patient medical records.

Step-by-step explanation:

The correct answer is 4) Clinical documentation improvement.

Clinical documentation improvement (CDI) is a form of clinical decision support that guides a user in appropriate documentation. It focuses on improving the accuracy and completeness of patient medical records, which in turn leads to more precise clinical decision making and better patient outcomes.

CDI programs provide guidelines and best practices to ensure that healthcare providers document all relevant patient information accurately and comprehensively. By doing so, CDI helps in coding for diagnoses, procedures, and treatments, as well as optimizing revenue cycle management.