Unit 7 Glossary

A program to improve the quality and completeness of clinical documentation to accurately reflect severity of illness and complexity of care. A formal communication tool used by CDI specialists or coders to request clarification of ambiguous, incomplete, or inconsistent documentation. Systematic review of health records to identify missing or incomplete elements (quantitative) or accuracy/consistency issues (qualitative). A health record that remains incomplete beyond the time period established by facility policy, typically 30 days post-discharge. The process by which providers formally verify their authorship of a health record entry, typically by electronic signature with date/time/credentials. Software that uses Natural Language Processing (NLP) to analyze clinical documentation and suggest ICD-10-CM/CPT codes. Formal management of data assets including policies, standards, stewardship roles, and controls ensuring data quality and security. An indicator required on Medicare inpatient claims showing whether a diagnosis was present at the time of admission.