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The healthcare industry faces several challenges due to unstructured documentation. Firstly, it can lead to inefficiencies in data management. Unstructured data is complex to search and analyze, slowing decision-making processes. Secondly, it can lead to inaccuracies in coding. If the CAC software misinterprets the information in the unstructured documentation, it can lead to incorrect codes being suggested, which can have severe implications for billing and compliance. Lastly, it can hinder Clinical Documentation Improvement (CDI) efforts. CDI aims to accurately represent a patient’s clinical status that can be readily used for ongoing patient care, research, and quality improvement. Unstructured documentation can make it challenging to achieve these goals.
SCIENCE
HEALTH SCIENCE
NURSING

 
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