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Clinical Terms & Vocabularies

Improving Clinical Documentation with Artificial Intelligence: A Systematic Review

Scott W. Perkins, BA, Justin C. Muste, MD, Taseen Alam, BS, and Rishi P. Singh, MD

This systematic review overviews peer-reviewed Artifical Intelligence (AI) tools to understand how AI may reduce opportunity cost.

By Jaehyeon Yun, Vishal Ahuja, Daniel F. Heitjan

Given the scope of Medicaid and the distinctive characteristics of the covered population, there is a need for readmission models that are designed for this set of patients. Here, the authors address this gap by using a large Medicaid claims database to develop a novel model for predicting the...
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Current Challenges in Sepsis Documentation and Coding: A Review of the Literature

By Jaime Sand, EdD, RHIA, CCS, CAHIMS and Alba Kuqi, MD, MSHIM

Challenges arise in sepsis billing due to the variety of definitions of the condition and changing clinical indicators impacting documentation and coding. This article reviews the literature related to the diagnosis, documentation, coding, and billing of sepsis since the more widespread...
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The Role of Clinical Decision Support Systems in Preventing Stroke in Primary Care: A Systematic Review

By Salha Fayea Alasiri, Abdel Douiri, Saffanah Altukistani, Talay Porat, Ola Mousa

Computerized clinical decision support systems (CDSS) are increasingly being used to facilitate the role of clinicians in complex decision-making processes. This systematic review evaluates evidence of the available CDSS developed and tested to support the decision-making process in primary...
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Extracting Data from the Electronic Health Record of Patients with ADHD Reveals Pediatricians’ Discussions of Educational Support and Document Collection

By Katherine Tennant Beenen, PhD, Nicole Garton, MD, Emily Carroll, BA, Ashley Tang, BS, Shamsi Berry, PhD, Kevin H. Lee, PhD, Theresa McGoff, MBA, RN, Neelkamal Soares, MD

Primary care physicians (PCPs) have an important role in the identification and management of Attention Deficit Hyperactivity Disorder (ADHD). There is a paucity of research on PCPs’ practices related to the discussion of educational interventions. We conducted a retrospective chart review...
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Procedure Code Utilization for Vascular Access Device Placement in the Inpatient Setting: A Retrospective Analysis

Erica DeBoer, RN, MA, CCRN-K, CNL, and Kimberly Alsbrooks, BSN, RN, RT (R), VA-BC

Vascular access (VA) is essential to inpatient care, and the documentation/coding practices for vascular access device (VAD) placement procedures remain unexplored. Accurate documentation may present benefits for patients, providers, and researchers. A retrospective analysis was performed in...
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