Clinical documentation is the foundation of every patient health record and a strong clinical documentation improvement (CDI) program is vital to providing meaningful information throughout a patient’s care.
A new American Health Information Management Association book, Clinical Documentation Improvement: Principles and Practice, defines CDI, explains its importance and outlines principles that can be applied in any healthcare organization’s CDI program.
Identifying the key users of clinical documentation – from patients to clinicians to coding professionals to reimbursement entities – author Pamela Carroll Hess, MA, RHIA, CCS, CDIP, CPC, explains how a strong CDI program affects them all.
“Clinical documentation is at the core of every patient encounter,” Hess says. “For it to be meaningful, it must be accurate, timely and reflect the full scope of the patient’s care. Successful CDI programs help facilitate the transfer of accurate information.”
The book addresses the fundamentals of clinical documentation, describes clinical documentation program implementation and recommends a process for growing and refining a clinical documentation program.
Key features of the book include:
- How the transition to ICD-10 will have an effect on the CDI process, highlighting specific coding scenarios.
- A chapter on critical thinking for physicians, nurses, clinical documentation specialists, and coders.
- Extensive guidance on CDI program analytics and their importance to a sustainable program.
- The latest on CDI technology solutions, an example query set, and work plans for CDI program implementation.
- Additional guidance on CDI for APR-DRG and quality scoring.
- Online appendices including an example presentation on physician education and engagement and strategy.
