Quality of care is recognized through the clinical documentation that supports accurate ICD code assignment. Thus, many clinical documentation improvement programs are now evolving to support quality initiatives.
We talk a lot about the impact of CDI on healthcare organizations and physicians. But do we take the time to look at the true extent of the impact CDI has on our patients?
Just as healthcare doesn’t stop when a patient is discharged, health problems begin before admission takes place. The documentation doesn’t start or stop at the acute admission either.
Even though the basics of high quality clinical documentation are the same in all areas of healthcare, the CDI program structure will differ between inpatient and outpatient areas.
As with any partnership in life, the relationship between the clinical documentation improvement specialist and the coding professional is crucial to the success of a CDI program.
When calculating the productivity guidelines for a CDI program it is important to remember both quantitative and qualitative perspectives.