MARGIE WHITE WELLNESS CENTER

Clinical Documentation Improvement Program (CDI)

Coded data quality is the cornerstone of data integrity and the

foundation for all service billing

Implement a Clinical Documentation Improvement Program (CDI) that meets our internal core needs and addresses

specific risks

Clinical documentation is the basis for all coding

done in every healthcare facility. An effective CDI

program can have a positive impact on the

accuracy of the reimbursement, quality ratings,

planning data, and the acquisition of data for

research purposes. It can also improve clinical

documentation and provide mechanism for the

coding staff to communicate with physicians.

The 7 Qualities for High-Quality Clinical Documentation:

Legible - Clear enough to be read and easily deciphered.

Reliable – Trustworthy & safe; yielding the same result when repeated.

Precise – Accurate, exact, & strictly defined; evidenced by the level of detail in the documentation.

Complete - Having the maximum content (thorough). All concerns in the record are addressed.

The 7 Qualities for High-Quality Clinical Documentation:

Consistent - Not contradictory. From start to finish, documentation makes sense in relation to the rest of the documentation in the record.Clear – Unambiguous, intelligible, and not vague; states the cause of the patient’s symptoms. Timely - At the right time.

GOALS OF A CLINICAL DOCUMENTATION

IMPROVEMENT PROGRAM

Goals of a Clinical Documentation Improvement Program

Establish ongoing monitor for identifying problems or opportunities to improve quality of coded data

Identify variations in coding practices among staff members

Determine cause and scope of identified problems

Set priorities for resolving identified problems

Goals of a Clinical Documentation Improvement Program

Implement mechanisms for problem solving through approval of corrective action plans

Ensure that corrective action is taken by following up on problems with appropriate monitors

Ensure compliance while meeting organizational needs

Key Types and Sources of Documentation

Attending Physician Documentation

Includes patient’s history and physical examination, problem list (plan of care for each problem), orders for treatment and services, documented condition, diagnostic test results, and response to treatment.

Key Types and Sources of Documentation

Consultants - Consultant report based on patient examination and review of the medical record.

House Staff – Interns, residents, and fellows may document the history and physical examination, operative reports, discharge summary, and progress notes.

Other physician documentation

Key Types and Sources of Documentation

Other Clinical Documentation – diagnosticians, midlevel practitioners, nurses, other specialty professionals, and medical students.

Diagnostic test results – such as laboratory results, pathology reports, and radiology reports.

Midlevel practitioners – including nurse practitioners, and physician assistants.

Key Types and Sources of Documentation

Nurses, Nutritionists, & Therapists

Documentation includes physical findings, educational efforts, treatments

provided, and patient’s response to those treatments

Steps to Development and Implementation of a CDI Program

Executive support - Including CEO, CFO

Medical staff support

Steps to Development and Implementation of a CDI Program

Medical staff Operations Finance HIM

Case management

Nursing Compliance Quality

Oversight Committee - Determine the mission and scope of the program. Develop a strategic communication plan and oversee operations of the program.

Steps to Development and Implementation of a CDI Program

Program staff: Clinical documentation specialists- Review records and interact with physicians Conduct follow-up education with physicians Physician staff: Program advisor Support for CDS staff

Works Cited

Schraffenberger, L. A., & Kuehn, L. (2011). Effective Management of Coding Services. Chicago: AHIMA.