CDI is a Quality Initiative
Clinical documentation is fundamental for every patient encounter. Clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data.
CDI can be viewed as the link between the physician's "clinical speak" and the diagnosis from a coding perspective. Coded data is then translated into quality reporting, physician report cards, physician and hospital reimbursement, public health data, and disease tracking and trending.
Accurate risk-adjustments, and severity-based outcomes reflect more accurately and fairly on quality of care provided.
Good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, validate the care that was provided and show compliance with quality and safety guidelines. Precise documentation and coding ensures that our clinical care accurately reflects the condition of our patients and the intensity of care we provide.
CDI professionals come most often from health information management (HIM) and nursing backgrounds. When documentation is incomplete, ambiguous or conflicting, the CDI specialist must seek clarification by asking the medical team to provide clarification by means of a “query”. The query must be answered in order for the request to be satisfied and for the documentation to be updated. These steps help ensure that the medical record accurately captures the patient’s condition, confirming the severity of illness and risk of mortality for the patient.
LGH is committed to ensuring high quality documentation that corresponds to the care that is delivered.