Clinical Documentation Improvement: Principles and Practice (EPUB)

By Pamela Carroll Hess

Clinical documentation serves as the cornerstone of every patient’s health record. This book provides a clear definition of clinical documentation, underscores its significance, and outlines a consistent set of principles that can be effectively applied within any healthcare organization’s clinical documentation improvement (CDI) program. The author highlights the primary stakeholders of clinical documentation—ranging from patients and clinicians to coding professionals and reimbursement entities—and explores how a robust CDI program impacts each group.

The book is divided into three key sections: Part 1 focuses on the essentials of clinical documentation, including evaluating the existing quality of an organization’s documentation and deciding whether to establish a new CDI program or enhance an existing one. Part 2 covers the implementation process, detailing steps such as staffing, training, physician queries, data analysis, and ensuring compliance with program standards. Part 3 proposes a strategy for refining and expanding a clinical documentation program.

Key highlights include:

• Insights into how the shift to ICD-10 affects CDI processes, with specific coding examples.
• A new chapter on critical thinking skills for physicians, nurses, clinical documentation specialists, and coders.
• Comprehensive guidance on CDI program analytics and their role in maintaining a sustainable program.
• Updated content on CDI technology solutions, sample query sets, and work plans for implementing CDI programs, APR-DRG CDI initiatives, and denials management.
• Additional resources on CDI for APR-DRG and quality scoring.
• Online appendices featuring a sample presentation on physician education, engagement, and strategy.