Clinical documentation is the foundation of every patient health record. This book clearly defines the term, explains its importance, and presents an objective and uniform set of principles that can be applied reliably in any healthcare organization ’s clinical documentation improvement (CDI) program. The author identifies the key users of clinical documentation—from patients to clinicians to coding professionals to reimbursement entities—and throughout the book addresses how a strong CDI program affects them all.
Part 1 addresses the fundamentals of clinical documentation—assessing the current quality of the organization’s documentation and making the decision to implement a new program or improve the current one. Part 2 describes clinical documentation program implementation—from staffing and training through querying physicians, analyzing program data, and ensuring program compliance. Finally, Part 3 recommends and explains a process for growing and refining a clinical documentation program.
"Designing and implementing clinical documentation improvement programs are critical components of managing health information for any healthcare organization. This book presents uniform principles for evaluating and improving clinical documentation as well as demonstrating the importance of CDI programs. It provides up-to-date information on the collaboration needed for ensuring quality clinical documentation in today's EHR systems, the importance of data analytics, and the use of CDI technology tools. It is a valuable resource for anyone who has a role or interest in CDI."
-- Linda Hyde, RHIA (Hyde Consulting) Doody's Review
This title is suitable for anyone who is involved in developing or maintaining a CDI system. It is also an appropriate book for educational programs that are introducing students to the need for and concepts behind CDI programs.