Clinical Documentation Improvement

Aerolib Healthcare Solutions helps healthcare organizations in developing both inpatient and outpatient care clinical documentation improvement programs to meet changing rules and regulations. The firm emphasizes the importance of documentation in the patient record by all participants in the process: triage, emergency room, attending physician, consultants and nursing staff. We help Physicians and Case managers understand the importance of predictability of adverse clinical events and how to document them to get appropriate bedding status. We identify institutional current practices and how to develop a compliance program to prevent future audits. Our Analytics process helps healthcare institutions develop new strategies to ensure ongoing regulatory compliance, provides new skills to participating healthcare providers and information to the case management and utilization teams to develop patient centered approach to Total Quality Management. Determining Audit Risk Score using the proprietary Aerolib Analytics summary helps determine individual case features. We have seen that inadequate documentation in the history & physical, discharge summary and daily progress notes can increase the score significantly.