Clinical documentation improvement
Clinical Documentation Improvement
Clinical Documentation Improvement (pronunciation: klin-i-kəl dä-kyü-mən-'tā-shən im-'pru̇v-mənt), often abbreviated as CDI, is a process used in healthcare to ensure that clinical documents are accurate, complete, and effective. The process involves the review and amendment of clinical documents to ensure they accurately reflect the patient's health status, care provided, and outcomes.
Etymology
The term "Clinical Documentation Improvement" is derived from the English language. "Clinical" (pronunciation: 'klin-i-kəl) is derived from the Greek word "klinikos", which means "of the bed". "Documentation" (pronunciation: dä-kyü-mən-'tā-shən) comes from the Latin word "documentum", which means "example, proof, lesson". "Improvement" (pronunciation: im-'pru̇v-mənt) is derived from the Anglo-French word "emprouwer", which means "to improve".
Related Terms
- Medical Coding: The process of translating medical reports into numeric or alphanumeric codes to accurately represent the services and procedures performed and the patient's diagnosis.
- Health Information Management: The practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care.
- Electronic Health Record (EHR): A digital version of a patient's paper chart, which contains the patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results.
- Clinical Documentation Specialist: A healthcare professional who is responsible for reviewing and improving the accuracy and completeness of patient records.
Importance of Clinical Documentation Improvement
Clinical Documentation Improvement plays a crucial role in patient care, healthcare delivery, and revenue cycle management. It ensures that the clinical data accurately reflects the patient's health status and the care provided, which is essential for patient safety, quality of care, and healthcare reimbursement.
Process of Clinical Documentation Improvement
The process of Clinical Documentation Improvement involves several steps, including:
- Review of the patient's medical record
- Identification of any discrepancies or missing information
- Querying the physician or healthcare provider for clarification, if necessary
- Amendment of the clinical documentation to accurately reflect the patient's health status and the care provided
- Education of healthcare providers on the importance of accurate and complete clinical documentation
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