Happy 8th Clinical Documentation Improvement Week
Annually, the third week of September is a time to celebrate Clinical Documentation Improvement (CDI) Professionals. According to an Association of Clinical Documentation Improvement Specialists (ACDIS) Fact Sheet, “the growth of the CDI specialist profession has mirrored the healthcare industry’s increased focus on compliance with regulations, quality of care improvement measurements, and liability exposure. All these factors increasingly depend on the integrity of complete and specific clinical documentation in the medical record.”
Part of the celebration includes designating a theme for the week.
- 2011: Paving the Path to an Accurate and Complete Health Record
- 2012: Physicians and Clinical Documentation Improvement Specialists Joining Forces in Clinical Documentation Excellence
- 2013: ICD-10: Preparing for Tomorrow Today
- 2014: CDI and Quality: Transforming Healthcare
- 2015: Branching Out Into Healthcare
- 2016: CDI in Concert Your Ticket to Collaboration
- 2017: Join Us on the Trail
- 2018: CDI Mosaic Creating a Collaborative Portrait
Looking back at all of the themes, it is evident that successes in CDI is a team effort. MMP would like to wish all of the hard working CDI professionals that we have the privilege to work with a happy CDI week. We also want to support your efforts by providing highlights from the fourth universal definition of myocardial infarction (MI) publication.
The American College of Cardiology (ACC), the American Heart Association (AHA), the European Society of Cardiology (ESC), and the World Heart Federation (WHF) recently simultaneously published the Fourth Universal Definition of Myocardial Infarction (2018). One key new concept is the differentiation of myocardial infarction (MI) from myocardial injury. Specifically, “although myocardial injury is a prerequisite for the diagnosis of MI, it is also an entity in itself…non-ischaemic myocardial injury may arise secondary to many cardiac conditions such as myocarditis, or may be associated with non-cardiac conditions such as renal failure.”
Acute myocardial infarction is defined as “when there is an acute myocardial injury with clinical evidence of acute myocardial ischaemia and with detection of a rise and/or fall of cardiac troponin (cTN) values with at least one value above the 99th percentile upper reference limit (URL) and at least one of the following:
- Symptoms of myocardial ischemia;
- New ischemic electrocardiogram changes;
- Development of pathological Q waves;
- Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with ischaemic etiology;
- Identification of a coronary thrombus by angiography or autopsy (not for types 2 or 3 MIs).”
Also included in this publication are the following new sections:
- Takotsubo syndrome,
- Myocardial infarction with non-obstructive coronary arteries (MINOCA),
- Chronic kidney disease,
- Atrial fibrillation,
- Regulatory perspective on myocardial infarction, and
- Silent or unrecognized myocardial infarction.
Again, happy CDI week from our team to yours.
Article by Beth Cobb
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.