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Understanding Clinical Documentation Improvement in Healthcare

by Dr Prem Community Writer
Clinical Documentation

Clinical Documentation Improvement (CDI) is the procedure used by healthcare providers to review individual clients’ clinical documents and provide feedback to the medical professional to improve its details. Since you can only code what is documented, it is crucial to fill in the blanks of what is documented to realize better coding, for instance, questions on coding, quality measures, and overall care and treatment administered to a patient.

Is CDI Important?

apointment with doctor

Healthcare facilities began Clinical Documentation Improvement programs to respond to the need for diagnosis-related groups (DRGs), a form of reimbursement. Most medical professionals keep receiving requests to provide supplementary documentation.

For instance, the codes representing the severity of an illness have a risk of mortality. This is done to avoid disqualifying healthcare professionals that care for sicker clients. Risk adjusting data levels the playing fields for all physicians.

Therefore clinical documentation improvement transforms into valid codes that fully capture the severity of an illness and mortality risk attached to it. It also reflects the intensity of healthcare services offered and resources used in caring for patients.

However, coding terminology and regulations differ from the universal clinical language, there’s a risk that the physicians will get lost in the translation process. This is where clinical documentation comes in handy.

A CDI program is a multi-disciplinary and comprehensive effort that aims to incorporate all the terminology required to precisely and articulately translate a patient’s condition into valid code.

The Key Player in a CDI Team

Clinical DocumentationThe key personnel on a CDI team are

  • Clinicians
  • Inpatient coders
  • Clinical documentation specialists (CDS)

Other members include those in the

  • Nutrition department
  • Wound care
  • Care management
  • The laboratory

In this aspect, clinicians refer to any recognized, licensed, and credentialed medical professional to diagnose and treat sick clients. They include:

  • Doctors of Osteopathic Medicine (DO)
  • Doctors of Pediatric Medicine (DPM)
  • Doctors of Medicine (MD)
  • Residents

Nurse practitioners

  • Physician assistants
  • Nurse anesthetists, among others

These medical professionals are key players in CDI because they are familiar with the clients and the conditions receiving treatment. Consequently, their documentation informs and controls all that happens.

CDI process has three components, namely:

  • Awareness
  • Competence
  • Collaboration

The role of the CDI specialist is to record every detail of the clinician documentation for the period a client is receiving treatment.

Next, the CDI specialist submits a request to other clinicians for clarification and additional documentation to assign a more precise coding.

Effective communication is crucial between a CDS and the patient coder because it ensures that the clinical documentation improvement is translated into the precise code that is a reflection of the patient’s condition.

Front-end inpatient coders should collaborate with the CDS and get training in the terminology most often used in the clinical improvement process.

Hospital managers must ensure there is close collaboration and consensus building, to run an effective CDI program. The institution’s values and objectives should also be shared.  In their absence, divisiveness and conflict prevail in the working environment. There should develop a unified reporting framework for both CDS and coders, to cure this challenge.

Article Submitted By Community Writer