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    Clinical Documentation Improvement Program

    Uploaded by

    Mohammed Gazo
    This document outlines a clinical documentation improvement (CDI) program policy for all staff at a medical center. It defines CDI and explains that accurate documentation is important for high quality patient care, coding, reimbursement, research, and compliance. The policy describes the importance of CDI for improving care quality and safety, reducing errors, justifying treatments, and ensuring accurate coding. It provides clinical documentation rules regarding medical record accuracy, diagnosis documentation, and continuity of care. Finally, it describes CDI audit and query procedures to address missing or conflicting documentation.

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    © All Rights Reserved
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    Clinical Documentation Improvement Program

    Uploaded by

    Mohammed Gazo
    180 views4 pages
    This document outlines a clinical documentation improvement (CDI) program policy for all staff at a medical center. It defines CDI and explains that accurate documentation is important for high quality patient care, coding, reimbursement, research, and compliance. The policy describes the importance of CDI for improving care quality and safety, reducing errors, justifying treatments, and ensuring accurate coding. It provides clinical documentation rules regarding medical record accuracy, diagnosis documentation, and continuity of care. Finally, it describes CDI audit and query procedures to address missing or conflicting documentation.

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    This document outlines a clinical documentation improvement (CDI) program policy for all staff at a medical center. It defines CDI and explains that accurate documentation is important for high quality patient care, coding, reimbursement, research, and compliance. The policy describes the importance of CDI for improving care quality and safety, reducing errors, justifying treatments, and ensuring accurate coding. It provides clinical documentation rules regarding medical record accuracy, diagnosis documentation, and continuity of care. Finally, it describes CDI audit and query procedures to address missing or conflicting documentation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    180 views4 pages

    Clinical Documentation Improvement Program

    Uploaded by

    Mohammed Gazo
    This document outlines a clinical documentation improvement (CDI) program policy for all staff at a medical center. It defines CDI and explains that accurate documentation is important for high quality patient care, coding, reimbursement, research, and compliance. The policy describes the importance of CDI for improving care quality and safety, reducing errors, justifying treatments, and ensuring accurate coding. It provides clinical documentation rules regarding medical record accuracy, diagnosis documentation, and continuity of care. Finally, it describes CDI audit and query procedures to address missing or conflicting documentation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Department : Management Of Page:

    Information (MOI) 1 of 4

    Policy Number :MOI - 8 Issue Date : 1-6-2021


    Replaces Number: New
    Effective Date : 1-6-2021

    Title : Clinical
    Documentation
    Applied To : All Staff
    Improvement (CDI) Program Review Date : 1-6-2024
    ‫جميع العاملين بالمركز‬

    Definition of CDI
    1. Clinical documentation is at the core of every patient encounter. In order to be
    meaningful, the documentation must be clear, consistent, complete, precise,
    reliable, timely, and legible to accurately reflect the patient’s disease burden
    and scope of services provided.
    2. Successful clinical documentation integrity (CDI) programs facilitate the
    accurate representation of a patient’s clinical status that translates into coded
    data. Coded data is then translated into quality reporting, physician report
    cards, reimbursement, public health data, disease tracking and trending, and
    medical research.
    3. The convergence of clinical care, documentation, and coding processes is vital
    to appropriate reimbursement, accurate quality scores, and informed decision-
    making to support high-quality patient care. To that end, CDI has a direct
    impact on patient care by providing information to all members of the care
    team as well as those who may be treating the patient at a later date.

    Importance of CDI
    1. Improving Clinical Documentation level that leads to better quality of care
    to all patient and enhancing the patient safety.
    2. Promote complete and precise clinical documentation ending up with
    patient safety, quality of care, better continuity of care, and mitigating risk
    management.
    3. Reduce the medical and medication errors.
    4. Mitigate the medico-legal claims.
    Department : Management Of Page:
    Information (MOI) 2 of 4

    Policy Number :MOI - 8 Issue Date : 1-6-2021


    Replaces Number: New
    Effective Date : 1-6-2021

    Title : Clinical
    Documentation
    Applied To : All Staff
    Improvement (CDI) Program Review Date : 1-6-2024
    ‫جميع العاملين بالمركز‬

    5. Justify the care, treatment, interventions prescribed to the patients.


    6. Achieving both efficiency and effectiveness in patient care using the
    updated evidence-based medicine and at the same time promoting better
    utilization of resources avoiding the overuse, underuse, and misuse.
    7. Rectify the missing, conflicting, nonspecific clinical documentation related
    to Both Diagnoses and Interventions.
    8. Assure the accurate diagnostic and interventional coding that leads to the
    appropriate reimbursement (ICD-10-Am, ACHI, AR-DRG), when applicable.
    9. Provide quality data for research, public reporting, national registries, and
    public health data.
    10.Improve the reimbursement from the third party payor, when applicable.
    11.Compliance with CBAHI’s Accreditation Standards.

    Clinical Documentation Rules:


    1. The medical record shall be accurate, complete, legible in hand writing,
    authorized.
    2. The physicians shall clearly document the history and physical examination,
    holistic assessment and reassessment, any required consults, care plan,
    interventions and treatments, comment on any diagnostics ordered to the
    patients.
    3. The physician shall make all efforts possible to reach the principal diagnosis
    that occasioned the episode of care or the reason behind the patient’s visit.
    4. The physician shall assign all the secondary diagnoses that may need extra
    medical attention or may affect the course of care given to the principal
    diagnosis.
    Department : Management Of Page:
    Information (MOI) 3 of 4

    Policy Number :MOI - 8 Issue Date : 1-6-2021


    Replaces Number: New
    Effective Date : 1-6-2021

    Title : Clinical
    Documentation
    Applied To : All Staff
    Improvement (CDI) Program Review Date : 1-6-2024
    ‫جميع العاملين بالمركز‬

    5. The physician shall elaborate in details on the medical conditions of the


    patient.
    6. If there is an infection, the physician shall tackle the causative organism as
    possible.
    7. If there is an injury, the physician shall tackle the causative agent, location
    the patient got injured within, the circumstances of the injury.
    8. Avoid abbreviations as possible unless it is accepted by an authorized
    policy.
    9. Avoid vague language in documenting the clinical findings and be specific to
    the utmost possibility.
    10. Ensure the continuity of care to the patients with all members of the care
    team with different specialties and disciplines.

    CDI Audit and Queries:


    1- The CDI specialist (Doctor or Nurse), shall concurrently and timely review all
    medical records or a sample as convenient and effective.
    2- If there is any missing or conflicting documentation, CDI specialist shall
    send a query to the physician in writing as possible whether paper-based or
    electronically or at least via a phone call if other means didn’t yield the
    required results .
    3- The physician shall properly respond to the query in 48 hours.
    Department : Management Of Page:
    Information (MOI) 4 of 4

    Policy Number :MOI - 8 Issue Date : 1-6-2021


    Replaces Number: New
    Effective Date : 1-6-2021

    Title : Clinical
    Documentation
    Applied To : All Staff
    Improvement (CDI) Program Review Date : 1-6-2024
    ‫جميع العاملين بالمركز‬

    Signature /‫التوقيع‬ Name‫ االســم‬/


    Title‫ الوظيفة‬/

    ‫إعـداد‬
    ‫مسؤول السجالت الطبية‬
    Prepared By

    ‫مديرة التمريض‬
    ‫مراجـعة‬
    ‫منسق الجودة‬
    Reviewed By
    ‫المدير الطبي‬

    ‫اعتماد‬
    ‫المدير العام‬
    Approved By

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