Clinical Documentation Improvement

Clinical Documentation Improvement assists physicians with accurate and complete documentation in order to better reflect the care patients receive. Complete documentation directly impacts hospitals’ and physicians’: 

  • Severity of Illness (SOI) 
  • Risk of Mortality (ROM) 
  • Insurance reimbursement 
  • Quality data

Clinical Documentation Specialists are nurses who review charts CONCURRENTLY (while the patient is in house) for proper documentation. We have expanded in the last 6 months with a goal of reviewing all: 

  • Adult inpatient records, excluding Behavioral Health 
  • Pediatrics/PICU records 
  • Women and Infants’ Center records 
  • Special Care Nursery records 

CDI also RETROSPECTIVELY (after discharge) reviews the charts of every patient who expires in the hospital. 

The CDI Team will be instrumental in the implementation of ICD-10. Measures we will be involved in to 
prepare physicians for ICD-10 include: 

  • Assessing current documentation to determine where increased specificity will be required with ICD-10, or if physicians are already documenting with enough specificity. 
  • Querying physicians for added specificity 
  • Developing specialty-specific educational materials to assist physicians in better understanding documentation requirements (newsletters, tip sheets, etc.) 
  • Assisting with the build of documentation templates for quicker/simpler documentation 

Resources