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Strong clinical documentation integrity (CDI) programs help translate a patient’s health status into coded data that supports everything from quality reporting to medical research. This blend of clinical care, documentation, and coding keeps care teams informed and helps guide decisions for patient care, both now and in the future.
CDI (Clinical Documentation Improvement) is the process of improving medical record documentation for completeness, specifics, and accuracy.
Clinical documentation integrity (CDI) programs help facilitate the precise representation of a patient’s clinical status. This toolkit will discuss many of the topics that new CDI professionals need to be aware of to develop a strong CDI practice.
Clinical documentation is the foundation of every health record in every setting. Clinical documentation is any manual or electronic notation made by a clinical care provider or their authorized “medical scribe.”
Clinical documentation integrity (CDI) programs help facilitate the precise representation of a patient’s clinical status. This is accomplished by reviewing health records to assure they meet high-quality clinical documentation standards that will translate into the appropriate coded data.
Clinical documentation improvement (CDI) programs play a vital role in today’s healthcare environment. The growth of the U.S. healthcare industry has resulted in increasingly demanding regulatory initiatives designed to promote improved quality of care while controlling future healthcare costs.
Based on the recent 2015 Clinical Documentation Improvement Trends Survey, real-time, one-on-one, patient-specific conversations are the most effective education strategy to make physicians aware of how to improve documentation