Clinical Documentation Improvement (CDI)

clinical Documentation Improvment (CDI)

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Clinical Documentation Improvement (CDI)

The world of medicine and medical services is witnessing recent trends and successive structural improvements in an effort to raise the level of quality and safety related to the patient.

As this trend prompted the establishment of new programs and departments that would play their role in improving the health system.

 A recent program has been developed in the region called Clinical Documentation Improvement (CDI), as complete and accurate documentation plays an important role in patient care.

What is Clinical Documentation Improvement (CDI)

 is a process to facilitate an accurate representation of healthcare provided through complete and precise reporting of diagnoses, comorbidities and procedures to ensure the acuity and complexity of the patient is available to be coded

Importance of CDI

Clinical documentation is the foundation of a patient’s medical record. It captures patient care from admission to discharge, including diagnoses, treatment and resources used during their care. When the documentation is complete, detailed, and accurate, it prevents ambiguity, and improves communication between healthcare providers. Conversely, incomplete or inaccurate documentation can adversely affect the quality of patients’ care, leading to medication errors, longer lengths of stay (LOS), inappropriate (or no) post-discharge patient follow-up, higher readmission rates and increased care costs.

How to create a CDI program

1.chart review from a clinical and coding perspective to assess gaps in documentation and their effects on coding – including resource intensity weight (RIW), coding deficiencies, harm metrics, length of stay (LOS) discrepancies – and identifying the areas that require attention and improvement to meet the organization’s goals.

2.  customized education for physicians, CDI specialists and/or health information management (HIM) professionals to make every medical record more accurate and valuable. This step also includes implementing queries (requesting clarification or specificity from the physician regarding a condition) and monitoring the query process.

3.  review of the program once CDI changes have been implemented, to evaluate the success of the program, and then monitoring changes/impact based on ongoing data analyses.

The importance of clinical documentation in healthcare improvement

Understanding the deficiencies in documentation or coding within a healthcare organization is the first step in identifying the need and requirements to improve clinical documentation, which enables us to begin the next steps to reach our goals In improving health care


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