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Dear Clinical Documentation Improvement Professional:
Welcome to the CDI Job Analysis Pilot Survey.
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| Clinical & Coding Practice |
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| How frequently do you use knowledge of medical terminology and anatomy and physiology in your job?
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| How important is knowledge of medical terminology and anatomy and physiology in performing your job?
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| How frequently do you use knowledge of pharmacology in your job?
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| How important is knowledge of pharmacology in performing your job?
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| How frequently do you use knowledge of pathophysiology and disease processes and treatment in your job?
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| How important is knowledge of pathophysiology and disease processes and treatment in performing your job?
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| How frequently do you use knowledge of diagnostic, laboratory and surgical procedures in your job?
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| How important is knowledge of diagnostic, laboratory and surgical procedures in performing your job?
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| How frequently do you use knowledge of definition of CC's, MCCs in your job?
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| How important is knowledge of definition of CC's, MCCs in performing your job?
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| How frequently do you use knowledge of encoder software, DRG grouper, and coding manuals in your job?
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| How important is knowledge of encoder software, DRG grouper, and coding manuals in performing your job?
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| How frequently do you use knowledge of complex clinical documentation in your job?
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| How important is knowledge of complex clinical documentation in performing your job?
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| How frequently do you use knowledge of assigning ICD-9 CM coding in your job?
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| How important is knowledge of assigning ICD-9 CM coding in performing your job?
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| How frequently do you use knowledge of assigning CPT coding in your job?
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| How important is knowledge of assigning CPT coding in performing your job?
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| How frequently do you use knowledge of DRG reimbursement methodologies in your job?
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| How important is knowledge of DRG reimbursement methodologies in performing your job?
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| How frequently do you use knowledge of coding references in your job?
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| How important is knowledge of coding references in performing your job?
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| How frequently do you use knowledge of definitions of principal and secondary diagnoses in your job?
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| How important is knowledge of definitions of principal and secondary diagnoses in performing your job?
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| How frequently do you use knowledge of procedural techniques in your job?
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| How important is knowledge of procedural techniques in performing your job?
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| How frequently do you use knowledge of effective communication skills in your job?
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| How important is knowledge of effective communication skills in performing your job?
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| How frequently do you use knowledge of presentation skills in your job?
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| How important is knowledge of presentation skills in performing your job?
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| How frequently do you use knowledge of conflict resolution in your job?
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| How important is knowledge of conflict resolution in performing your job?
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| How frequently do you use knowledge of interpretation of statistical reports in your job?
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| How important is knowledge of interpretation of statistical reports in performing your job?
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| How frequently do you use knowledge of performance audits in your job?
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| How important is knowledge of performance audits in performing your job?
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| How frequently do you use knowledge of AHIMA practice beliefs in your job?
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| How important is knowledge of AHIMA practice beliefs in performing your job?
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| How frequently do you use knowledge of professional organizations available for resource in your job?
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| How important is knowledge of professional organizations available for resource in performing your job?
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| Record Review & Documentation Clarification |
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| How frequently do you use knowledge of AHIMA and compliance standards related to query process in your job?
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| How important is knowledge of AHIMA and compliance standards related to query process in performing your job?
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| How frequently do you use knowledge of medical record structure in your job?
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| How important is knowledge of medical record structure in performing your job?
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| How frequently do you use knowledge of national patient safety indicators in your job?
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| How important is knowledge of national patient safety indicators in performing your job?
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| How frequently do you use knowledge of core measures in your job?
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| How important is knowledge of core measures in performing your job?
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| How frequently do you use knowledge of best practices for clinical documentation in your job?
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| How important is knowledge of best practices for clinical documentation in performing your job?
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| How frequently do you use knowledge of best practices for data integrity in your job?
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| How important is knowledge of best practices for data integrity in performing your job?
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| How frequently do you use knowledge of development of statistical graphs and reports in your job?
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| How important is knowledge of development of statistical graphs and reports in performing your job?
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| How frequently do you use knowledge of statistical reports in your job?
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| How important is knowledge of statistical reports in performing your job?
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| How frequently do you use knowledge of effective reporting and communication techniques in your job?
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| How important is knowledge of effective reporting and communication techniques in performing your job?
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| How frequently do you use knowledge of CDI benchmark metrics in your job?
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| How important is knowledge of CDI benchmark metrics in performing your job?
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| How frequently do you use knowledge of presentation and spreadsheet software in your job?
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| How important is knowledge of presentation and spreadsheet software in performing your job?
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| How frequently do you use knowledge of effective presentation techniques for behavior modification in your job?
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| How important is knowledge of effective presentation techniques for behavior modification in performing your job?
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| How frequently do you use knowledge of Coding Clinics and other reference resources in your job?
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| How important is knowledge of Coding Clinics and other reference resources in performing your job?
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| How frequently do you use knowledge of communication skills in your job?
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| How important is knowledge of communication skills in performing your job?
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| How frequently do you use knowledge of writing skills in your job?
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| How important is knowledge of writing skills in performing your job?
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| How frequently do you use knowledge of variety of uses of clinical data within an organization in your job?
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| How important is knowledge of variety of uses of clinical data within an organization in performing your job?
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| How frequently do you use knowledge of web navigational skills in your job?
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| How important is knowledge of web navigational skills in performing your job?
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| How frequently do you use knowledge of CDI trends and best practices in your job?
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| How important is knowledge of CDI trends and best practices in performing your job?
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| How frequently do you use knowledge of privacy concepts in your job?
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| How important is knowledge of privacy concepts in performing your job?
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| How frequently do you use knowledge of security concepts in your job?
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| How important is knowledge of security concepts in performing your job?
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| How frequently do you use knowledge of key components of data records exchange in your job?
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| How important is knowledge of key components of data records exchange in performing your job?
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| How frequently do you use knowledge of fraud and abuse regulations in your job?
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| How important is knowledge of fraud and abuse regulations in performing your job?
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* When will you most likely need to obtain knowledge in navigation of electronic health records (EHRs) to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in EHR reporting metrics, standards and criteria to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in EHR design for patient safety to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in principles of usability of EHRs to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in the Legal Health Record to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in meaningful use criteria to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in quality measures to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in automated data sources for quality measures to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in Computer Assisted Coding application software to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in resources to assist in data dictionary creation to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in clinical data content design and construction to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in best practices for data integrity automation to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in best practices for clinical documentation automation to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in sources of data for clinical quality measures to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in continuity of Care documents to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in process flow mapping and workflow analytics to continue your professional development in clinical documentation improvement?
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* When will you most likely need to obtain knowledge in principles of change management to continue your professional development in clinical documentation improvement?
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| Clinical & Coding Practice |
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| How frequently do you use coding conventions in your job?
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| How important is it for you to use coding conventions in performing your job?
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| How frequently do you assign and sequence ICD9-CM codes in your job?
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| How important is it for you to assign and sequence ICD9-CM codes in performing your job?
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| How frequently do you assign appropriate DRG codes in your job?
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| How important is it for you to assign appropriate DRG codes in performing your job?
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| How frequently do you assign CPT and/or HCPCS codes in your job?
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| How important is it for you to assign CPT and/or HCPCS codes in performing your job?
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| How frequently do you use coding software in your job?
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| How important is it for you to use coding software in performing your job?
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| How frequently do you display knowledge of Payer requirements for appropriate code assignment(e.g. CMS, APR,APG) in your job?
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| How important is it for you to display knowledge of Payer requirements for appropriate code assignment(e.g. CMS, APR,APG) in performing your job?
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| How frequently do you use reference resources for code assignment in your job?
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| How important is it for you to use reference resources for code assignment in performing your job?
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| How frequently do you participate in educational sessions with staff to discuss infrequently encountered cases in your job?
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| How important is it for you to participate in educational sessions with staff to discuss infrequently encountered cases in performing your job?
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| How frequently do you communicate with the coding/ HIM staff to resolve discrepancies between the working and final DRGs in your job?
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| How important is it for you to communicate with the coding/ HIM staff to resolve discrepancies between the working and final DRGs in performing your job?
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| How frequently do you communicate with coding/ HIM staff to resolve discrepancies in documentation for CPT assignment in your job?
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| How important is it for you to communicate with coding/ HIM staff to resolve discrepancies in documentation for CPT assignment in performing your job?
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| How frequently do you identify the principal and secondary diagnoses in order to accurately reflect the patient’s hospital course in your job?
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| How important is it for you to identify the principal and secondary diagnoses in order to accurately reflect the patient’s hospital course in performing your job?
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| How frequently do you maintain affiliation with professional organizations devoted to the accuracy of diagnosis coding and reporting in your job?
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| How important is it for you to maintain affiliation with professional organizations devoted to the accuracy of diagnosis coding and reporting in performing your job?
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| How frequently do you promote CDI efforts throughout the organization in your job?
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| How important is it for you to promote CDI efforts throughout the organization in performing your job?
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| How frequently do you develop documentation improvement projects in your job?
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| How important is it for you to develop documentation improvement projects in performing your job?
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| How frequently do you foster working relationships with CDI team members for reconciliation of queries in your job?
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| How important is it for you to foster working relationships with CDI team members for reconciliation of queries in performing your job?
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| How frequently do you establish a chain of command for resolving unanswered queries in your job?
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| How important is it for you to establish a chain of command for resolving unanswered queries in performing your job?
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| How frequently do you establish consequences for non-compliance to queries or lack of responses to queries in collaboration with providers in your job?
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| How important is it for you to establish consequences for non-compliance to queries or lack of responses to queries in collaboration with providers in performing your job?
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| How frequently do you collaborate with physician champions to promote CDI initiatives in your job?
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| How important is it for you to collaborate with physician champions to promote CDI initiatives in performing your job?
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| How frequently do you develop CDI policies & procedures in accordance with AHIMA practice briefs in your job?
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| How important is it for you to develop CDI policies & procedures in accordance with AHIMA practice briefs in performing your job?
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| Record Review & Document Clarification |
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| How frequently do you collaborate with the case management and utilization review staff to effect change in documentation in your job?
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| How important is it for you to collaborate with the case management and utilization review staff to effect change in documentation in performing your job?
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| How frequently do you identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity in your job?
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| How important is it for you to identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity in performing your job?
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| How frequently do you query providers in an ethical manner to avoid potential fraud and/or compliance issues in your job?
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| How important is it for you to query providers in an ethical manner to avoid potential fraud and/or compliance issues in performing your job?
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| How frequently do you identify post-discharge query opportunities that will affect SOI, ROM and ultimately, case weight in your job?
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| How important is it for you to identify post-discharge query opportunities that will affect SOI, ROM and ultimately, case weight in performing your job?
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| How frequently do you formulate queries to providers to clarify the clinical significance of abnormal findings identified in the record in your job?
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| How important is it for you to formulate queries to providers to clarify the clinical significance of abnormal findings identified in the record in performing your job?
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| How frequently do you formulate queries to providers to clarify conflicting diagnoses in your job?
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| How important is it for you to formulate queries to providers to clarify conflicting diagnoses in performing your job?
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| How frequently do you interact with providers to clarify POA in your job?
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| How important is it for you to interact with providers to clarify POA in performing your job?
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| How frequently do you interact with providers to clarify PSI in your job?
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| How important is it for you to interact with providers to clarify PSI in performing your job?
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| How frequently do you interact with providers to clarify HAC in your job?
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| How important is it for you to interact with providers to clarify HAC in performing your job?
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| How frequently do you interact with providers to clarify the documentation of core measures in your job?
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| How important is it for you to interact with providers to clarify the documentation of core measures in performing your job?
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| How frequently do you track responses to queries and interact with providers to obtain query responses in your job?
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| How important is it for you to track responses to queries and interact with providers to obtain query responses in performing your job?
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| How frequently do you develop policies regarding various stages of the query process and time frames to avoid compliance risk in your job?
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| How important is it for you to develop policies regarding various stages of the query process and time frames to avoid compliance risk in performing your job?
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| How frequently do you determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities in your job?
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| How important is it for you to determine facility requirements for documentation of query responses in the record to establish official policy and procedures related to CDI query activities in performing your job?
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| How frequently do you ensure provider query response is documented in the medical record in your job?
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| How important is it for you to ensure provider query response is documented in the medical record in performing your job?
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| How frequently do you track denials and documentation practices to avoid future denials in your job?
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| How important is it for you to track denials and documentation practices to avoid future denials in performing your job?
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| How frequently do you perform quality audits of CDI content to ensure compliance with institutional policies & procedures or national guidelines in your job?
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| How important is it for you to perform quality audits of CDI content to ensure compliance with institutional policies & procedures or national guidelines in performing your job?
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| How frequently do you compare institution with external institutional benchmarks in your job?
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| How important is it for you to compare institution with external institutional benchmarks in performing your job?
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| How frequently do you measure the success of the CDI program through dashboard metrics in your job?
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| How important is it for you to measure the success of the CDI program through dashboard metrics in performing your job?
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| How frequently do you use CDI data to adjust departmental workflow in your job?
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| How important is it for you to use CDI data to adjust departmental workflow in performing your job?
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| How frequently do you track data for CDI benchmarking and trending in your job?
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| How important is it for you to track data for CDI benchmarking and trending in performing your job?
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| How frequently do you trend and track physician query content in your job?
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| How important is it for you to trend and track physician query content in performing your job?
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| How frequently do you trend and track physician query volume in your job?
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| How important is it for you to trend and track physician query volume in performing your job?
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| How frequently do you trend and track physician query response in your job?
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| How important is it for you to trend and track physician query response in performing your job?
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| How frequently do you track working DRG (CDS) and coder final code in your job?
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| How important is it for you to track working DRG (CDS) and coder final code in performing your job?
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| How frequently do you trend and track physician and query provider in your job?
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| How important is it for you to trend and track physician and query provider in performing your job?
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| How frequently do you track data for physician benchmarking and trending in your job?
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| How important is it for you to track data for physician benchmarking and trending in performing your job?
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| How frequently do you track data for specialty benchmarking and trending in your job?
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| How important is it for you to track data for specialty benchmarking and trending in performing your job?
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| How frequently do you articulate the implications of accurate coding with respect to research, public health reporting, case management and reimbursement in your job?
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| How important is it for you to articulate the implications of accurate coding with respect to research, public health reporting, case management and reimbursement in performing your job?
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| How frequently do you monitor changes in the external regulatory environment in order to maintain compliance with all applicable agencies in your job?
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| How important is it for you to monitor changes in the external regulatory environment in order to maintain compliance with all applicable agencies in performing your job?
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| How frequently do you research and adapt successful best practices within the CDI specialty that could be utilized at ones own organization in your job?
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| How important is it for you to research and adapt successful best practices within the CDI specialty that could be utilized at ones own organization in performing your job?
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| How frequently do you educate the appropriate staff on the clinical documentation improvement program including accurate & ethical documentation practices in your job?
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| How important is it for you to educate the appropriate staff on the clinical documentation improvement program including accurate & ethical documentation practices in performing your job?
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| How frequently do you articulate the implications of accurate coding in your job?
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| How important is it for you to articulate the implications of accurate coding in performing your job?
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| How frequently do you educate providers and other members of the health care team about the importance of the documentation improvement program and the need to assign diagnoses and procedures when indicated, to their highest level of specificity in your job?
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| How important is it for you to educate providers and other members of the health care team about the importance of the documentation improvement program and the need to assign diagnoses and procedures when indicated, to their highest level of specificity in performing your job?
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| How frequently do you develop educational materials to facilitate documentation that supports severity of illness, risk of mortality and utilization of resources in your job?
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| How important is it for you to develop educational materials to facilitate documentation that supports severity of illness, risk of mortality and utilization of resources in performing your job?
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| How frequently do you consult with compliance and HIM department regarding legal issues surrounding CDI efforts in your job?
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| How important is it for you to consult with compliance and HIM department regarding legal issues surrounding CDI efforts in performing your job?
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| How frequently do you apply regulations pertaining to CDI activities in your job?
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| How important is it for you to apply regulations pertaining to CDI activities in performing your job?
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| How frequently do you apply AHIMA best practices related to CDI activities in your job?
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| How important is it for you to apply AHIMA best practices related to CDI activities in performing your job?
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* Do you create data definitions for your organization?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you create data definitions for your organization?
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| * When do you expect you and/or your organization will create data definitions for your organization? |
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* Are you involved in EHR content design?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently are you involved in EHR content design?
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* When do you expect you and/or your organization will be involved in EHR content design?
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* Are you involved in EHR and documentation improvement workflow and GAP analysis?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently are you involved in EHR and documentation improvement workflow and GAP analysis?
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| * When do you expect you and/or your organization will be involved in EHR and documentation improvement workflow and GAP analysis? |
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* Do you help define what data is included in or excluded from the EHR?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you help define what data is included in or excluded from the EHR?
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| * When do you expect you and/or your organization will help define what data is included in or excluded from the EHR? |
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* Do you evaluate usability of data in the EHR?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you evaluate usability of data in the EHR?
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* When do you expect you and/or your organization will evaluate usability of data in the EHR?
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* Do you design EHR alerts, reminders, clinical decision support to support documentation improvement?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you design EHR alerts, reminders, clinical decision support to support documentation improvement?
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| * When do you expect you and/or your organization will design EHR alerts, reminders, clinical decision support to support documentation improvement? |
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* Do you educate others in the proficient use of the EHR?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you educate others in the proficient use of the EHR?
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* When do you expect you and/or your organization will educate others in the proficient use of the EHR?
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* Do you provide feedback on EHR systems usability to physicians and other clinicians?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you provide feedback on EHR systems usability to physicians and other clinicians?
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* When do you expect you and/or your organization will provide feedback on EHR systems usability to physicians and other clinicians?
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* Are you involved in implementing care protocols?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently are you involved in implementing care protocols?
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| * When do you expect you and/or your organization will be involved in implementing care protocols? |
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* Do you create continuum of care documents?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you create continuum of care documents?
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| * When do you expect you and/or your organization will create continuum of care documents? |
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* Compile disparate data into understandable summary form?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you compile disparate data into understandable summary form?
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| * When do you expect you and/or your organization will compile disparate data into understandable summary form? |
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* Are you involved in implementing critical paths or evidence-based medicine?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently are you involved in implementing critical paths or evidence-based medicine?
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* When do you expect you and/or your organization will be involved in implementing critical paths or evidence-based medicine?
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* Are you involved in the integration of data from external sources into the medical record?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently are you involved in the integration of data from external sources into the medical record?
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* When do you expect you and/or your organization will be involved in the integration of data from external sources into the medical record?
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* Do you help define sources of clinical data for quality measures and reporting?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you help define sources of clinical data for quality measures and reporting?
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* When do you expect you and/or your organization will help define sources of clinical data for quality measures and reporting?
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* Do you review & recommend revisions to Computer Assisted Coding?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you review & recommend revisions to Computer Assisted Coding?
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* When do you expect you and/or your organization will review & recommend revisions to Computer Assisted Coding?
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* Do you communicate HIM principles and expertise in regards to clinical data content and integrity to clinicians?
Which domain does this task belong in? |
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| * Are you currently performing this task? |
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| How frequently do you communicate HIM principles and expertise in regards to clinical data content and integrity to clinicians?
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| * When do you expect you and/or your organization will communicate HIM principles and expertise in regards to clinical data content and integrity to clinicians? |
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| * Professional Affiliations: | | |
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