Overview
Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient’s disease burden and scope of services provided.
Successful clinical documentation integrity (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.
The convergence of clinical care, documentation, and coding processes is vital to appropriate reimbursement, accurate quality scores, and informed decision-making to support high-quality patient care. To that end, CDI has a direct impact on patient care by providing information to all members of the care team as well as those who may be treating the patient at a later date.
Training and Resources
AHIMA is committed to advancing CDI by providing education and training, certification (CDIP® credential), and other valuable resources to CDI professionals. Whether you are new to CDI, transitioning from a coding or clinical background, or an experienced CDI professional, AHIMA provides education and resources to support your lifelong learning and continued advancement.
Online Courses
Critical Thinking in Health Record Review and Data Analysis
This course will help CDI professionals to think critically and evaluate patient encounters for accurate diagnostic capture and coding. The online lessons also help CDI professionals to better gather data and analyze public and internal reports.
1 COURSE | 18 CEUS
Certified Documentation Integrity Practitioner (CDIP®) Preparation Course
The American Health Information Management Association (AHIMA) Certified Documentation Integrity Practitioner (CDIP) credential is recognized as a symbol of a CDI professional’s outstanding clinical and coding competency, leadership skills, and commitment to excellence. The CDIP preparation course is a comprehensive series of five modules that represent the five domains tested on the CDIP exam.
CDI and Quality Outcomes Training
The CDI and Quality Outcomes course provides information on the impact CDI programs have on quality reporting within various healthcare settings. This course is composed of three modules, each focuses on a specific healthcare setting.
Certified Coding Specialist (CCS®) Training for CDI Clinicians
This course was designed for clinicians working in CDI who are preparing to take the Certified Coding Specialist (CCS) exam. The course delivers a comprehensive overview of the CCS exam as well as a practice exam.
18 lessons | 26.5 CEUs
Self-Paced Clinical Documentation Improvement (CDI) Inpatient-Outpatient Academy
The Self-Paced CDI Inpatient-Outpatient Academy is a comprehensive series of 18 lessons that cover the best practices of CDI.
Books
eBook | First Edition
Clinical Documentation Improvement: Principles and Practice
Learn the fundamentals of clinical documentation, how to implement a CDI program, and how to grow and refine an existing program.
Hardcover | First Edition
Certified Documentation Improvement Practitioner (CDIP) Exam Preparation
This book is for experienced CDI professionals to test their knowledge regarding high-quality documentation and prepare to sit for AHIMA's CDIP exam.
Hardcover | First Edition
Clinical Documentation Improvement for Outpatient Care
This is an all-inclusive guide to establishing and enhancing CDI programs for the outpatient and professional fee setting.
eBook | Sixteenth Edition
2023 CDI Pocket Guide® Unbound Edition
Take your clinical documentation integrity (CDI) department completely online and mobile.
Webinars
On-Demand | Up to 3 CEUs
The Impact of Technology on Clinical Documentation Integrity
This three session series guides CDI professionals through their artificial intelligence (AI) CDI program journey. Sessions highlight the benefits of AI in CDI programs, the role CDI professionals play in integrating and managing CDI technology, and the process of auditing the AI process in CDI programs.
Resources
Practice Brief | Available for download
Guidelines for Achieving a Compliant Query Practice
Download the Brief to learn best practice standards for the clinical documentation integrity query process. The new AHIMA-ACDIS practice brief serves as an essential resource for coding and clinical documentation integrity (CDI), and other healthcare professionals with the underlying goal of validating the clinical documentation within the health record to accurately represent the clinical status of the patient.
Clinical Documentation Integrity (CDI) Progression Ladder
The CDI Progression Ladder represents and supports all stages of a CDI professionals career, including the educational level of each product.
AHIMA Query Template Library
A compliant query process is an essential element of a CDI program. AHIMA has developed a query template library that includes more than 140 templates covering documentation needs in both inpatient and outpatient settings.
Clinical Validation Practice Brief
Are you struggling to maintain consistency and accuracy in clinical validation within your organization? Clinical validation is a crucial process that demands seamless collaboration between providers, clinical documentation integrity (CDI) specialists, and coding professionals. We understand the challenges when it comes to identifying diagnoses that lack clinical evidence. That's why we're excited to introduce our new Clinical Validation Practice Brief! Get started with essential guidance and tools to incorporate clinical validation seamlessly into your daily workflow.