Clinical Documentation Improvement

Improving clinical documentation leads to revenue gains and most healthcare facilities are now exploring this program.  The main reason for getting into this program is to improve your reimbursements and that will happen with improved documentation and coding.  However, it is important to set specific goals when putting together a Clinical Documentation Improvement (CDI) program for your facility.

Here are some goals that you can keep in mind when building your CDI program:

  • Aim for your facility to become well-organized
  • Improve quality of patient care with reliable medical records
  • Clarify coding and documentation with an established query process
  • Work with the provider to establish documentation expectations
  • Schedule audit and monitoring on a regular basis

It is important to understand the three processes that you need to take into consideration, in order to create an effective and manageable CDI program – assessment, implementation and maintenance.


Healthcare facilities establishing a CDI program need to perform an objective assessment on the existing quality of documentation and coding.  It is important to understand if the deficiencies are due to ambiguous documentation, lack of physician documentation or coding interpretation issues.  Evaluate if your current system is in place for clinical documentation

  • Identify areas that may require improvement or corrections through a baseline medical record audit
  • Assess physician education and training for the CDI program
  • Analyze your payment and denial pattern and set specific goals for the providers and your staff
  • Separate audits for therapeutic and diagnostic procedures
  • Keep focus on level 1-5 visits, not just level 4 and 5
  • Choose a model based on your requirements
  • Bell curve data and practitioner utilization to be reviewed


  • Bring your staff on board and make them aware of the importance of each task
  • Ensure that everything required for implementation – work space, tools, personnel are in place
  • Establish a training program and encourage CDI orientation for staff credentialing
  • Implement changes based on your audit
  • Work with your CDI provider to set up a customized program based on the audit results
  • Identify areas requiring further improvements or corrections
  • Develop compliant, meaningful queries and assign a staff to monitor and manage them


  • Set up a monitoring schedule with the provider
  • Set up regular training and education programs for the staff
  • Conduct additional audits regularly to find areas that need improvement
  • Work with the provider to make adjustments to the program, based on the audits

A successful CDI program promotes complete, accurate and compliant documentation; established through analysis and interpretation of health record documentation. This in turn leads to identification and rectification of situations where there is insufficient documentation to support the patient’s care.  Staff needs to be trained to formulate physician queries, analyze data and monitor the program’s performance.  In addition they also should be able to communicate with HIM staff, administrators and physicians successfully.

Contact us at for assistance with your clinical documentation.

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