医療の必要性を文書化し、この参照ツールを使用してSOIを記述するためにこちらをご覧ください。
The Elsevier CDI Reference Mobile Application is a clinical documentation improvement (CDI) quick reference tool designed to pinpoint for, clinicians and CDI staff, clinical terms or phrases that may be used to accurately and completely describe, in detail, a specific condition. Specific documentation may be used to demonstrate medical necessity for services, justify admission and treatment, and accurately reflect a patients severity of illness. Emphasis is placed on necessary documentation for the ICD-10-CM/PCS coding system. Physician documentation should NEVER include information that is enhanced, modified, or otherwise inaccurate for the purposes of determining or increasing payment, or for any other situation in which a physician or facility may falsely gain.