Clinical Documentation Improvement

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Introduction The Clinical Documentation Improvement (CDI) program has continued to provide a pathway for improving Physician’s clinical documentation. This requires a collaborative effort from the Health Information Management (HIM) professionals to assist the Physicians in maintaining a sound health record to enhance clinical clarity. From the onset, the use of CDI program has continued to thrive in all healthcare settings across the United States (especially in the hospitals) as a holistic approach to promote effective data quality reporting. Expanding the CDI initiative into ambulatory and outpatient settings have become an increased focus for the CDI specialist to ensure a smooth data reporting. Beyond these measures, many private …show more content…

Thus, to address the Physicians about the CDI program, I will need to know the audience I will be working with whether they are mid-level Physicians or academic physicians and approached each differently with the intent to acquire sufficient information about their understanding of clinical documentation improvement and Physician query process. I will then work with them to determine the area of where maintaining a sound health record is lacking as well as to identify gaps in their knowledge about CDI programs. In addition, the Physicians will be assessed to find out what they know about clinical documentation improvement using questionnaires. Departmental meetings will be conducted on a regular basis to inform the Physicians the goal of conducting queries to ensure clarity, consistency and completeness of patients’ medical health record. A face-to-face interview will also be conducted with the pool of practicing Physicians to determine their readiness for change. In addition, I will review the Physician’s understanding of the American health information management (AHIMA) guidelines for clinical documentation improvement (CDI) which will be carried out during the face-to-face interview to ensure they are onboard with the organization’s strategic goal on maintaining a complete health record. The Physicians’ will also be provided with training and education on CDI program that includes information on why queries are being utilized across the hospital to help overcome their fears of maintaining a sound and complete health records. According to Rosenbaum et al. (2013), educating the Physicians is a significant step for a hospital “to enhance and ensure useful and appropriate documentation of the medically indicated care that is delivered”

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