Clinical documentation is at the core of every patient encounter. In order to be meaningful it must be accurate, timely, and reflect the scope of services provided. Successful clinical documentation improvement (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, and disease tracking and trending.
The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle, and more important, to a healthy patient. 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 downstream who may be treating the patient at a later date.
A CDI program includes a myriad of people, processes, and technology that must work together to ensure success. Organizations need a well-rounded individual who can effectively articulate all the pieces: documentation requirements, code assignment, coding guidelines, and quality reporting.
CDI professionals come to the role from a variety of backgrounds, the two backgrounds seen most often are health information management (HIM) professionals and nurses. HIM professionals, through their education, are familiar with compliant documentation rules and regulations as well as accreditation standards that affect timely documentation. In addition, HIM professionals are also familiar with important areas such as privacy, security, and confidentiality that also impact sharing of clinical information. Nurses have a strong clinical background which helps them identify gaps in the clinical evidence and documentation. Both of these backgrounds provide a good foundation to become a CDI professional.
AHIMA is committed to advancing clinical documentation improvement (CDI) by providing education and training, certification, 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.
Now, more than ever, CDI professionals are in high demand. By obtaining AHIMA’s Certified Documentation Improvement Practitioner (CDIP®) certification, professionals distinguish themselves as knowledgeable and competent in this field.
Learn more about the CDIP certification and resources to prepare for the exam.
CERTIFIED DOCUMENTATION IMPROVEMENT PRACTITIONER (CDIP): ADVANCING THE PRACTICE ONLINE COURSES
The CDIP Exam Prep online courses are designed to prepare CDI professionals to sit for the exam by reviewing the six domains covered in the CDIP exam. Real-world examples and learning activities are incorporated into the training, and there are more than 100 review questions to prepare for the exam.
Clinical Documentation Improvement: Principles and Practice
Identifies the fundamentals of clinical documentation, how to implement a CDI program, and how to grow and refine an existing program.
Certified Documentation Improvement Practitioner (CDIP®) Exam Preparation
Clinical documentation improvement (CDI) competencies are becoming more valued in healthcare professionals of all kinds, including health information management (HIM) professionals, nurses, and physicians. Test your knowledge of these concepts and prepare to sit for AHIMA's Certified Documentation Improvement Practitioner (CDIP®) examination with this guide, which includes two full exams comprised of 280 total questions.
Clinical Documentation Improvement for Outpatient Care
Outpatient clinical documentation improvement (CDI) is a vital step in the evolution of a comprehensive, overarching CDI program. Clinical Documentation Improvement for Outpatient Care: Design and Implementation is an all-inclusive guide to establishing and enhancing CDI programs for the outpatient and professional fee setting. It explains how to ensure sustainability and is a one-stop shop for information about regulatory changes that affect the healthcare industry.
Diving into Documentation Webinar Series-These are monthly 30-minute presentations created and presented by CDI industry experts. Each presentation will be pre-recorded and available on-demand.
View all Diving Into Documentation Webinars.
CDI Webinars available for purchase
Medical Residents as Key Players in Clinical Documentation
AHIMA offers a number of resources to assist organizations, CDI professionals and those interested in a career in CDI.
HIM Body of Knowledge™ Online Library
Monthly Blog: Documentation Detective
Infographic: The CDI Journey
Practice Briefs and Toolkits Member only resource
A strong clinical documentation integrity (CDI) program makes a difference in achieving the goals of RAC audits, ARRA/HITECH, and other important initiatives to improve the quality of healthcare. In response to industry demand, the Commission on Certification for Health Informatics and Information Management (CCHIIM) developed the CDIP credential.
AHIMA supports quality documentation and the integrity of the patient’s health record through gold-standard CDI education, training, and testing. Professionals who hold AHIMA’s CDIP credential show that they are:
CDIP certification supports:
To sit for the CDIP exam, candidates must meet one of these eligibility requirements:
Our alliance with Artifact Health lets coding and CDI professionals using Artifact’s time-saving mobile app access over 100 AHIMA compliant query templates for inpatient, outpatient, and pediatric settings. Artifact makes it simple for physicians to respond quickly and compliantly to coding and CDI queries from their smartphone or computer.
Speed up query workflow. Hospitals and health systems using the Artifact platform report sustained response rates of nearly 100 percent, average response times within 48 hours for all queries, and significant reductions in discharged, not final billed days.
Ensure compliant queries. AHIMA’s template library standardizes query workflow across your organization and helps HIM and CDI leadership easily manage and maintain query templates.
Enhance visibility and accountability. Monitor all query activity with real-time dashboards and reports in Artifact. Coders and CDI professionals are therefore empowered to build quality improvements throughout the entire coding lifecycle.
The alliance between AHIMA and Artifact Health yields turnkey benefits:
Improve the quality of your patient records by streamlining the query workflow with Artifact and AHIMA. Learn how this major health system simultaneously improved physician response rates and mitigated CDI and coding teams resolution efforts.
Download a complete list of AHIMA’s templates here.