All About Clinical Documentation Improvements and Its Benefits

clinical documentation improvement

Clinical documentation is a crucial part of running a medical practice, regardless of what type of clinic you run. This documentation contains important information regarding a patient’s care.

As the name implies, clinical documentation improvement (CDI) is the process of improving clinical documentation and coding for things like claims reimbursement. As a healthcare provider, you need to fully understand how to improve your clinical documentation to maintain an efficient practice and improve patient care and convenience

If you’re not sure where to start, don’t worry. PracticeForces is a leading provider of medical billing and coding solutions. From helping you understand what a modifier in medical billing is to explaining how to streamline health information management, we can help your coding business and practice thrive. 


The Basics of Clinical Documentation Improvement

How exactly does the CDI process work? To start, clinical documentation improvement aims to streamline health records in order to establish more accurate reimbursements and better-quality data. All in all, the goal of CDI is to create better outcomes for patients and make medical providers’ jobs easier when it comes to document management and billing.

Clinical documentation improvement aims to make the patient’s essential information readily available, easy to read, and completely accurate. Successful CDI implementation should result in more readable results and better patient diagnoses and care. 


Creating an Effective CDI Plan

Now that you know what CDI is, you need to establish a plan to enact it. But where do you start?

Typically, a CDI plan is hospital-wide. It should be a comprehensive team effort that includes:

  • Correct terminology when describing patients’ unique conditions
  • Team of medical professionals that check medical records’ accuracy


Who Should Use a Clinical Documentation Improvement Program?

The three main professionals who use CDI programs are clinicians, clinical documentation specialists (CDS), and inpatient coders. 

Clinicians here can refer to:

  • Doctors of medicine
  • Nurse practitioners
  • Nurse anesthetists
  • Doctors of podiatric medicine
  • And more

Clinicians like those listed above are especially familiar with the different conditions and treatments of their patients. As such, having their input is essential for a successful CDI plan.

Meanwhile, clinical documentation specialists who have a Certified Documentation Integrity Practitioner (CDIP) credential are in charge of reviewing the collected information and relative medical records while the patients are in the hospital. They can go to clinicians and ask for any clarifications needed or additional documents to make sure that they assign the right codes to the right records.

Finally, inpatient coders double-check that these codes correctly reflect the patient’s condition. Inpatient coders often have extensive training in things like clinical terminology so that they can produce more effective and accurate results. 


Maximize Revenue and Improve Patient Care with CDI

Clinical documentation improvement brings many worthwhile benefits both for a clinic and its patients. PracticeForces can help you learn more about how proper CDI and healthcare revenue cycle management are the keys to running a successful practice. Give us a call today at (727) 270-8511 today to get started. 

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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