What Is Clinical Documentation Improvement (Plus Benefits)

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What Is Clinical Documentation Improvement? (Plus Benefits)

Hospitals and physicians need accurate information systems to provide the best care and follow-up for their patients. Clinical documentation improvement ( CDI) is a process for improving documentation and coding for claims reimbursement that involves multiple specialists and members of the medical staff. If you work in the healthcare industry, you might benefit from learning more about CDI. In this article, we discuss what a clinical documentation improvement plan is, who is involved and its elements and benefits.

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What is clinical documentation improvement?

Clinical documentation https://clinical-docs.blogspot.com/2023/07/bserved-to-solve-clinical-documentation.html improvement is the process of enhancing healthcare records to establish accurate reimbursements, higher-quality data and better patient outcomes. It ensures patient information is available, accurate and readable and results in correct orders , diagnoses and patient care. A successful clinical documentation improvement program provides an accurate clinical status of each patient. This status translates into:

  • Coded data used for public health

  • Physician report cards

  • Disease tracking

  • Medical research

  • Quality reporting

CDI is essential to achieving the highest standards of patient care. Therefore, health providers and regulatory agencies recognize the importance of investing in quality clinical documentation.

CDI programs started when healthcare facilities began using the diagnosis-related groups (DRGs) reimbursement system. Although the process began in hospitals, more physicians recognize its importance and apply it in all types of practices. CDI helps hospitals and doctors supply additional information to support International Classification of Disease (ICD) codes and improve data collection and hospital reimbursement. CDI makes medical records more organized, complete, accurate and consistent.

What is a clinical documentation improvement plan?

A clinical documentation improvement plan is a hospital-wide, multidisciplinary and comprehensive effort to include the proper terminology when describing a patient's condition so it translates into the correct codes. A CDI program involves a team of healthcare professionals that confirms the accuracy of medical record documentation, ensuring it displays the correct diagnosis, the care patients receive for their conditions and the quality of that care.

Who uses clinical documentation improvement programs?

Clinical documentation specialists (CDS), inpatient coders and clinicians use CDI programs. Here are their roles in a CDI plan:


Clinicians involved with CDI might include licensed healthcare professionals such as doctors of medicine (MD), https://utilization-services.blogspot.com/2023/07/bserved-your-reliable-partner-in.html nurse practitioners, nurse anesthetists, doctors of podiatric medicine (DPM), doctors of osteopathic medicine (DO), physician assistants, residents and more. Other healthcare members of the CDI team include wound care, laboratory or care management employees. Clinicians are familiar with the patient and https://www.educapyme.com/ the conditions they treat, so their input is crucial to a CDI. Their documentation affects every step that follows.

Clinical documentation specialists

Clinical documentation specialists review medical records and collect useful clinical information while patients are in the hospital. They ask clinicians for clarification or additional documentation to ensure they assign the correct codes to patient records. Most CDS requests are made in person to ensure accurate and effective communication. They also educate clinicians by giving presentations at medical staff conferences and meetings. The CDS exchange information with the inpatient coder, who translates the clinician's documentation into codes. CDSs usually report to the nursing department.

Inpatient coders

Inpatient coders make sure medical codes reflect the patient's condition. They receive training in the diagnostic criteria and https://training.farmingadviceservice.org.uk clinical terminology they encounter in the CDI process. They learn to improve coding guidelines, sequencing and code selection. Coders usually report to the hospital's chief officer.

Elements of a clinical documentation improvement plan

The three components an organization should include early in a clinical documentation improvement program include:

Physicians' input

A CDI plan involves physicians and their input. This step ensures the CDI plan is patient-centered. To recruit a lead physician, the CDI team should pick one who:

  • Is a good communicator

  • Is passionate about clinical documentation

  • Has leadership skills

The physician receives documentation education and training either from a consultant or an educational program so they can establish themselves as the hospital's CDI expert. Clinician CDI participation has three parts: awareness, competence and collaborative detailed query documentation.

CDI leaders

CDI leaders are certified through the American Health Information Management Association. Successful CDI leaders typically have experience in pharmacy, nursing or health information management. They understand payer-specific, federal and state requirements for coding, reporting and documentation. CDI professionals are aware of all the elements of high-quality clinical documentation, so their team can accurately describe the patient's condition in all healthcare settings.

Quality information

Stakeholders review CDI policies and procedures, and the program's staff signs off on them annually. The CDI team also ensures their clinical documentation is:

  • Reliable

  • Consistent

  • Clear

  • Legible

  • Complete

  • Timely

  • Precise

Advantages of clinical documentation improvement

Here are the benefits of CDI plans:

Reduced reimbursement denials

An effective CDI program helps reduce reimbursement denials and improve the appeals process, thanks to better clinical documentation. It promotes the correct description of a patient's clinical status that translates into an accurate code, which is necessary for reimbursements.

Increased Revenue

Hospitals that set up clinical documentation improvement usually see their revenue and claim reimbursements increase. Adopting CDI also optimizes the hospital's use of high-value specialists.

Improved medical records

From a clinical perspective, the main benefits of CDI are more meaningful patient data and information and more useful medical records. It ensures accurate descriptions of health conditions and creates electronic documents for every step of the patient's treatment and services.

Increased CMI

Hospitals that implement CDI usually see an increase in their case mix index (CMI), which is an indicator of hospital performance. It represents the average diagnosis-related group figures for the hospital using this formula: DRG weights for all Medicare discharges divided by the total number of discharges.

Increased time for patients

Administrative tasks and data entry can cause physicians to spend less time with their patients. CDI incorporates workflow tools that improve documentation quality. It also allows caregivers to spend more time connecting with and https://clinical-docs.blogspot.com/2023/07/bserved-to-solve-clinical-documentation.html caring for patients because they can create patient charts in less time.

Improved accuracy

Better documentation procedures and tools improve the accuracy of inpatient care. Proper care can boost a medical institution's reputation and save lives. CDI increases a hospital's success rate.

Improved patient care

CDI provides every member of a patient's current and future care team with accurate information. Clear information about an individual's diagnosis and treatment can lead to better clinical care. CDI also involves tools and guidance that ensure patient care is a priority.