Clintegrity Abstracting

Enhance abstracting productivity

A single, enterprise-wide solution

Clintegrity Abstracting is designed for today’s abstracting challenges. On the single Clintegrity platform with Clintegrity Coding, Compliance, Record Management, and Electronic Document Management (EDM) modules, Clintegrity Abstracting enhances productivity and streamlines coding and workflow processes throughout your organization. It is web based and enables real-time access to electronic health information and can be securely accessed anywhere, anytime to meet your remote coding and abstracting needs.


Create abstracting processes that work they way you do

This enterprise-wide solution, stores data from multiple facilities within the same database. A single access point facilitates advanced reporting and data analysis. It is tailored to meet your needs. Customizable data collection fields, rules and screen design enables you to tailor your abstracting processes to work the way that you do, while increasing productivity.

Features
  • A comprehensive list of data elements and the option to create new data elements to match current and future data collection and reporting needs
  • Unique data tabs based on facility and patient type
  • Enhanced HIPAA compliance tools with audit trails that track all data collection changes and events
  • User-defined field/page navigation
  • Ability to enable logic-driven data collection

Point-of-entry program

The best way to get the record straight - right from the start

As more and more patients are admitted through your Emergency Department, accurate documentation is becoming critically important. Due to the complexity of ED cases, the hectic work environment and the need to make rapid decisions, in many cases patient acuity is inaccurately reflected by under-documentation of the patient's clinical situation. Staff may accurately document the injury that brought the patient in, but miss secondary diagnoses and/or pre-existing conditions. What's more, a problem list isn't usually created until the patient is moved onto the floor...if ever. Improving the quality of the clinical documentation promotes better communication and creates an opportunity to positively impact clinical outcomes.

Nuance has developed a powerful solution and a new clinical staff position to help you ensure better clinical outcomes and accurate reimbursement.

The solution: Clintegrity CDI Point of Entry Program

Because documentation of critical information starts in the Emergency Department, the Point of Entry program starts there too - evaluating the severity of illnesses, assessing present-on-admission (POA) conditions, determining patient status (observation or inpatient), ensuring compliance with quality core measures, creating a problem list at the point of entry, and enabling more accurate documentation. The Point of Entry program builds on the foundation of Clintegrity CDI; and takes it even further, providing comprehensive clinical integration management.

New role: Clinical Integration Specialist

With this new solution comes a new clinical role - the Clinical Integration Specialist (CIS). This individual works closely with your clinical team to ensure all clinical observations are documented appropriately from the ED to discharge.

Your CIS is trained to:
  • Perform hands-on patient assessments
  • Identify and secure documentation of POA conditions
  • Assist with quality indicators such as core measures and patient safety indicators
  • Establish a problem list at the point of entry
  • Facilitate accurate, compliant clinical documentation by providing concurrent support to physicians
  • Review medical records for completeness and accuracy
  • Maintain liaison with ED and inpatient case manager and CDS
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Clintegrity Abstracting

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