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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.

 

18 CEUs and CNEs

Coming in 2021: CDI Trainer

  • AHIMA’s advanced workshop prepares CDI professionals to train others in industry best practices.
  • Learn how to teach complex subjects to include health record reviews, compliant queries and important CDI metrics.

November 13, 2020

The Need for Clinical Documentation Integrity in Critical Access Hospitals

Critical access hospitals must be just as prepared as noncritical access facilities to receive patients of varying acuity. This includes ensuring high-quality clinical documentation integrity.

Read full article at Journal of AHIMA

November 13, 2020

Evaluation and Management in 2021: What every HIM Professional Needs to Know (Part 1)

Since the most commonly reported professional services are Evaluation and Management codes, it seems fitting and timely that the rules for compliance with the documentation of these services should be reevaluated and revised to improve quality of care to patients and to reduce administrative burden.

Read full article at Journal of AHIMA

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.

Read full article at Journal of AHIMA

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