Clinical Documentation Integrity Education & Training | AHIMA
Strong clinical documentation integrity (CDI) programs help translate a patient’s health status into coded data that supports everything from quality reporting to medical research. This blend of clinical care, documentation, and coding keeps care teams informed and helps guide decisions for patient care, both now and in the future.
What Is Clinical Documentation Improvement (CDI)? - AAPC
2024年1月29日 · Clinical documentation improvement (CDI) is the process of reviewing medical record documentation for completeness and accuracy. CDI includes a review of disease process, diagnostic findings, and what documentation might be missing.
Clinical documentation improvement - Wikipedia
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT ...
Clinical documentation is any manual or electronic notation made by a clinical care provider or their authorized “medical scribe.” In the rapidly changing healthcare environment, patients, providers, health plans, regulatory initiatives, and organizations are recognizing the need for accu-rate, timely, and consistent documentation.
Clinical documentation integrity (CDI) programs help facilitate the precise representation of a patient’s clinical status. This is accomplished by reviewing health records to assure they meet high-quality clinical documentation standards that will translate into the appropriate coded data.
Clinical Documentation Integrity - The American Health …
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.
Clinical documentation improvement (CDI) programs play a vital role in today’s healthcare environment. The growth of the U.S. healthcare industry has resulted in increasingly demanding regulatory initiatives designed to promote improved quality of care while controlling future healthcare costs.
Clinical Documentation Integrity | AHIMA Body of Knowledge™
The discipline of clinical documentation integrity (CDI), whether practiced by clinicians or coding professionals, has the potential to deliver great value to the healthcare system—including to the patient, who deserves a clear, concise, consistent, and accurate health record to support continuity of care.
Studies have shown that improving high quality clinical documentation improves patient outcomes, and allows for better planning, delivery of services and appropriate funding. Physicians and other health care providers typically are not trained to develop proper documentation skills in medical school and residency.
What is Clinical Documentation Improvement (CDI)? - Consensus
Discover the importance of clinical documentation improvement (CDI) in healthcare, its benefits, challenges, and key strategies for a successful CDI program. Gain insights into why CDI matters and how it impacts patient care.