Mastering Clinical Documentation Improvement (CDI) Programs: A Comprehensive Guide

Clinical documentation is the backbone of every patient health record, and a strong Clinical Documentation Improvement (CDI) program is essential for any healthcare organization. In this book, Pamela Carroll Hess provides a clear definition of clinical documentation, explains its significance, and presents a set of objective and uniform principles that can be applied reliably in any CDI program.

Understanding the Importance of Clinical Documentation

The author identifies the key stakeholders of clinical documentation, including patients, clinicians, coding professionals, and reimbursement entities, and explains how a robust CDI program affects each of them. By implementing a strong CDI program, healthcare organizations can improve patient care, reduce costs, and ensure compliance with regulations.

A Comprehensive Guide to CDI Program Implementation

The book is divided into three parts, each focusing on a different aspect of CDI program implementation. Part 1 addresses the fundamentals of clinical documentation, including assessing the current quality of an organization’s documentation and making the decision to implement a new program or improve an existing one. Part 2 describes the implementation process, including staffing and training, querying physicians, analyzing program data, and ensuring program compliance. Part 3 provides guidance on growing and refining a clinical documentation program, including strategies for sustainability and continuous improvement.

Key Features and Updates

• Explores the impact of the transition to ICD-10 on the CDI process, with specific coding scenarios and examples
• Includes a new chapter on critical thinking for physicians, nurses, clinical documentation specialists, and coders
• Offers extensive guidance on CDI program analytics and their importance to a sustainable program
• Covers the latest CDI technology solutions, including an example query set and work plans for CDI program implementation, APR-DRG CDI program, and denials management
• Provides additional guidance on CDI for APR-DRG and quality scoring, with online appendices including an example presentation on physician education and engagement and strategy

Published by the American Health Information Management Association, this comprehensive guide is essential reading for healthcare professionals, clinical documentation specialists, and coders seeking to improve their organization’s CDI program.