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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.

 

Practice Brief | July 10, 2020

Evolving Roles in Clinical Documentation Integrity: A Provider’s Guide to the Art of Documentation

The purpose of this Practice Brief is to describe documentation best practices and serve as a resource in effective and efficient clinical documentation practices without having a negative impact on…

Read full article at Journal of AHIMA

CE Quiz | July 1, 2020

Integrating COVID-19 into CDI and Coding Practice

Because US providers’ experiences with COVID-19 have differed widely across the country, now is a good opportunity to regroup and assess what we think we know about the virus and how it could impact clinical documentation integrity (CDI) and coding professionals in the future.

Read full article at Journal of AHIMA

June 1, 2020

Documenting COVID-19

Clinical documentation integrity professionals need to educate providers on the importance of accurately documenting the presentation of COVID-19 patients.

Read full article at Journal of AHIMA

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