CDI efforts require in-depth knowledge of documentation requirements, coding classification standards and guidelines, and reporting requirements, in addition to an understanding of clinical records. AHIMA offers large collection of resources to support these efforts, and also offers the Certified Documentation Improvement Practitioner credential. Find eligibility requirements and exam preparation here.
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AHIMA’s Articles
Some of the articles on CDI in the AHIMA BoK include the following:
- Ethical Standards for Clinical Documentation Improvement (CDI) Professionals
- "Bridging the Gap on CDI," Journal of AHIMA 83 no. 2
- "CDI Opportunities for HIM Professionals," Journal of AHIMA 80, no. 10
- "Clinical Documentation Improvement: Gauging the Need, Starting off Right," Journal of AHIMA 80, no. 9
- “Leading Clinical Documentation Improvement: Three Successful HIM-led Programs,” Journal of AHIMA 79, no. 7
- “Getting Quality Clinical and Coded Data: How UMHS's CDIP Improved Clinical Coded Data and Clinical Staff Relationships,” Journal of AHIMA 78, no. 9
- “Clinical Documentation Specialists,” Journal of AHIMA 78, no. 7
- "Establishing a CDI Program: How One Organization Leveraged Nursing and Coding Skills to Improve Clinical Data," Journal of AHIMA 81, no. 7
- "Managing Physician Queries in the EHR," Journal of AHIMA 82, no. 7
- "Documentation Trends in the Health Record," Journal of AHIMA 83 no. 3
External Article
Didn’t find what you’re looking for? Visit the BoK to search the full online library of resources. The BoK is designed to enable HIM professionals to easily access the information needed to be successful professionals. Anchored by AHIMA-owned content and complemented by links to public material, the Body of Knowledge encompasses the theory and practice of HIM.
In the AHIMA BoK, you can conduct your own searches or view articles, practice briefs, and other published materials specifically related to a topic. The AHIMA BoK contains a wealth of information on documentation improvement issues. Some content is restricted to use by AHIMA members; selected content is made available to the healthcare industry at large. Here are links to a compilation of materials:
AHIMA Practice Briefs
AHIMA practice briefs provide practical and consensus-based guidance on best practices for a wealth of health information management (HIM) topics, including CDI. Some CDI-related practice briefs are listed here:
Guidance for Clinical Documentation Improvement Programs. Journal of AHIMA 81, no.5 (May 2010):45-50
Understanding HACs and SREs for Quality Reporting and Reimbursement, Journal of AHIMA 80, no. 9 (September 2009)
Managing an Effective Query Process, Journal of AHIMA 79, no. 10 (October 2008)
Quality Data and Documentation for EHRs in Physician Practice, Journal of AHIMA 79, no. 8 (August 2008)
Evolution of DRGs, Journal of AHIMA (Updated April 2010), web exclusive
Maintaining a Legally Sound Health Record—Paper and Electronic, Journal of AHIMA 76, no. 10 (November-December 2005)
AHIMA Position Statements
AHIMA Position statements relevant to CDI include:
AHIMA Toolkits and Models
AHIMA creates and makes toolkits and models available to the healthcare industry to support HIM practice. For example, the following resources are available to support CDI efforts:
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