Clinical documentation improvement (CDI) helps ensure that the events of the patient encounter are captured accurately and the electronic health record properly reflects the services that were provided. CDI also ensures that all members of the care team receive information on a patient, AHIMA added.
What is the purpose of a clinical documentation improvement program?
The overall goal of a CDI program is to improve clinical documentation, coding, and reimbursement. From a reimbursement perspective, an effective CDI program can reduce denials and improve the appeals process using improved clinical documentation.
What is the purpose of clinical documentation?
1. The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. The primary purpose of clinical documentation is to facilitate excellent care for patients.
What is the main focus of clinical documentation improvement?
The goal of CDI is to ensure that clinical documentation of diagnoses and services provided in the patient record are specific enough to support the assignment of accurate diagnostic and procedural codes (McDonald, 2015; Shepheard, 2018).
How does CDI improve patient care?
CDI strategies enable professionals to meticulously enter coded data related to a patient’s treatment. Accurate data helps everyone on the medical care team understand a patient’s status, and helps prevent malpractice due to illegible handwriting or unclear patient notes in an EHR.
What is the goal of CDI?
Successful clinical documentation integrity (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data.
What is the role of CDI?
The CDI professional reviews the medical record on a concurrent basis to identify or obtain clarification for the appropriate principal diagnosis, secondary diagnoses and the principal procedure. The medical record is evaluated for completeness, consistency, precision, clarity, and legibility.
What is the purpose of documentation?
Documentation is any communicable material that is used to describe, explain or instruct regarding some attributes of an object, system or procedure, such as its parts, assembly, installation, maintenance and use. Documentation can be provided on paper, online, or on digital or analog media, such as audio tape or CDs.
What are the benefits of clinical documentation improvement CDI )?
Clinical documentation improvement (CDI) helps ensure that the events of the patient encounter are captured accurately and the electronic health record properly reflects the services that were provided.
Why is documentation so important?
Documentation help ensure consent and expectations. It helps to tell the narrative for decisions made, and how yourself or the client responded to different situations. In this same manor, it is important to record information that can help support the proper treatment plan and the reasoning for such services.
How is CDI measured?
In CDI this is usually measured by the number of reviews completed, which is typically reported in a percentage of the records reviewed. The equation for this measurement would be the total number of records reviewed divided by the total volume that should have been reviewed.
What is a CDI policy?
PURPOSE: This policy addresses the required processes that should be followed for implementing, and/or maintaining a Clinical Documentation Improvement (CDI) Program that appropriately identifies the diagnoses, conditions and/or procedures that are representative of the patient’s severity of illness, risk of mortality,
What is a CDI Professional?
CDI professionals act as intermediaries between Inpatient coders who translate diagnoses into data and healthcare providers and nurses.
How can medical documentation be improved?
Some key factors of effective healthcare documentation include:
- Provide factual, consistent, and accurate input.
- Update the information after any recordable event.
- Make sure all information is current.
- Confirm that all entries are legible and signed.
What are the different types of medical documents?
01 Oct 6 different types of medical documents
- PIL. A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy.
- Medical history record.
- Discharge Summary.
- Medical test.
- Mental Status Examination.
- Operative Report.
Who are users of clinical documentation?
The author identifies the key users of clinical documentation—from patients to clinicians to coding professionals to reimbursement entities—and throughout the book addresses how a strong CDI program affects them all.