AN acute care setting should have a trained professional skilled in coding, disease process, record content knowledge, great communication skills, and be able to review records for details needed for appropriate reimbursements (Sayles, 2014, pg. 121).
Improving the accuracy of clinical documentation can reduce compliance risk, minimize a healthcare facility’s vulnerability during audits, and provide insight to legal quality of care issues. Clinical documentation improvement has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date (AHIMA,