Over the years, technology is making a strong impact in the world. Be it the healthcare industry or other organization: everyone is using different technologies to enhance their business. When it comes to healthcare, different standard terms are used. For instance, Protected Health Information (PHI) is associated with HIPAA. 

It describes the past, present, and future health status of a patient maintained by a HIPAA covered entity. Another term that is commonly used in healthcare is Clinical Documentation Improvement (CDI). It is also known as clinical documentation integrity and incorporates the terminologies needed to translate a patient’s condition into different codes. 

After the documentation is converted into numeric codes, the data generates results based on clinical outcomes. CDI professionals work as an intermediate between Inpatient coders (clinical coding officer) who convert the diagnosis into data. Clinicians play a crucial role in CDI. They know the patient scenarios and the conditions they are suffering from. Inpatient coders should not only collaborate with the CDS but also know the clinical terminologies that are encountered in the CDI process. 

To see the result: the documentation should be complete, clear, and reliable, and consistent. A clinical documentation integrity program facilitates the representation of a patient’s clinical data and translates into coded data. 

The data is then transferred into physician report cards, public health data, and other information. Clinical Document Information (CDI) has a strong impact on patient care and provides information to the members of the team. CDI improves daily operations and patient care processes. 

When doctors take notes, they are helping to enhance communication in their practices and providing a better community of care. Several healthcare organizations have started investing in automated solutions to improve clinical notes. 

Here are several steps that should be taken to improve clinical documentation. 

The staff members should understand the documentation standard; however, it should be improved frequently. 

The Healthcare Financial Management Association explained that organizations would benefit from providing structured training on documentation to existing employees. More information should be updated when EHR software upgrades are implemented. 

Document Improvements is a great way to reduce EHR vendors or third-party trainers. When the member knows everything about the documentation practices, a peer-to-peer system is created. A member of the team is responsible for keeping an eye on new documents. 

Not many members review the past information, but reviewing the old documents can be beneficial in improving the accuracy of EHRs. Checking on prior physical examinations improves the completeness of the document. 

It is clear that while managing documents, the physicians can make errors. When patients review their medical reports, they might find errors that could be important in optimizing treatment. It enables patients to view their health status and to improve their records.

American Medical Association (AMA) in a 2016 study found that every hour, the healthcare experts spend time with the patient, and then spend more time on EHR documentation. They spend nearly 25% of their time interacting with the patient and around 50% on EHR documentation. 

Former President of AMA, Steven J. Stack, said, 

He added, 

It increases revenue as a result of reduced errors and accurate medical coding. It also identifies the risk adjustment scores and shares better treatment to patients. It consistently coordinates with regulations and helps healthcare providers to make a smooth transition. It reduces claim details. 

By using CDI, it ensures that claims are completed and are filed on time. It allows physicians to add information and to complete patients’ records.  This way, medical coders conduct medical reviews of patient documents and assign codes with precision. 

When patient information is recorded, it provides a great healthcare experience not only to the patient but also to everyone who has access to the patient’s health records. Using CDI enables the provider and billing company to access records related to the patient. 

The organizations should analyze their current clinical documentation and revenue cycle performance. They should identify the documentation issues in key quality measures and hierarchical condition categories. Understanding the gaps helps the experts to focus on programs where revenue is most prevalent. 

The CDI team must include improvement specialist, Certified Clinical Documentation Specialist, and Clinical Documentation Improvement Practitioner. The leaders should decide whether automated documentation is appropriate or not. 

The clinical documentation specialist’s work is to review the medical record while the patient is in the hospital, and then to submit the reviewed document for clarification. 

The specialist should have a discussion with healthcare experts for better communication. Remember that every site has a different CDI. While some sites need to focus on accurate coding, others are great at maximizing patient results. 

CDI programs focus on different areas, including management coding and evaluation, ICD-10 diagnosis codes, and CPT procedure codes.