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.
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.
18 CEUs and CNEs
Coming in 2021: CDI Trainer
September 23, 2020
Ensuring Compliant CDI Query Scenarios for COVID-19
Obtaining clinical documentation that captures the patient’s SOI and ROM should be the objective of every clinical documentation integrity (CDI) program.
September 4, 2020
COVID’s Impact on the Future of HIM: Coding, CDI, and ROI
In this virtual roundtable, three HIM experts share insights gleaned from their experiences during the initial COVID-19 outbreak. The focus is on challenges and best practices in coding, clinical documentation improvement, and release of information.
August 19, 2020
The Revenue Impact of CDI and Coding Mismatches and Physician Query Analysis
Collaboration between clinical documentation integrity (CDI) specialists and health information management coding professionals is key to a successful CDI program as well as the evaluation of the revenue impact on the healthcare facility.