Clinical Documentation Improvement Program
Clinical Documentation Improvement Program
Clinical Documentation Improvement Program
Information (MOI) 1 of 4
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
Title : Clinical
Documentation
Applied To : All Staff
Improvement (CDI) Program Review Date : 1-6-2024
جميع العاملين بالمركز
Title : Clinical
Documentation
Applied To : All Staff
Improvement (CDI) Program Review Date : 1-6-2024
جميع العاملين بالمركز
Title : Clinical
Documentation
Applied To : All Staff
Improvement (CDI) Program Review Date : 1-6-2024
جميع العاملين بالمركز
إعـداد
مسؤول السجالت الطبية
Prepared By
مديرة التمريض
مراجـعة
منسق الجودة
Reviewed By
المدير الطبي
اعتماد
المدير العام
Approved By