| Clinical documentation improvement program is | | | | from customizing the technology and incorporating it |
| becoming more and more common in hospitals as | | | | into your current system, to ensuring that the hospital |
| they are realizing the importance of proper | | | | staff understands the program and implements it |
| documentation in the running of the organization. The | | | | successfully. In-corporations which specialize in CDI |
| following article describes the various types of clinical | | | | programs are being roped in by hospital administration |
| documentation being used. | | | | to manage and scrutinize the program and to ensure |
| A noticeable revolution is taking place in the way health | | | | that its objectives are met. A CDI program educates |
| care sector is rated and reimbursed. New laws are | | | | the hospital staff by providing strategies and |
| also being introduced making hospitals sit up and take | | | | approaches that aid them to document each patient's |
| notice. This turnaround in the health-care performance | | | | case from the very moment he or she enters the |
| evaluation and compensation has made the | | | | hospital. Most programs provide a process that |
| documentation process very decisive and significant. | | | | summarizes the difficulty levels and is replicated in your |
| Regulatory reforms are throwing light on the | | | | Case Mix Index. |
| importance of maintaining accurate clinical | | | | A good clinical documentation improvement program |
| documentation. The kind of reimbursement is directly | | | | ensures that the documentation is in accordance with |
| influenced by the patient's true records which has well | | | | The Coding Clinic and ICD-9-CM Official guidelines. |
| portrayed all relevant data. Thus, the need for clinical | | | | With a proper CDI program in place, it would be easier |
| documentation improvement program to address the | | | | to make sure that the documentation supports apt |
| above issues and to avoid unnecessary inquiry into the | | | | reimbursement and prevents the risk of non- |
| general scheme of things. | | | | compliance. CDI program helps to improve quality of |
| The focus of documentation teams should be to | | | | care with specific documentation. This helps in better |
| enhance the quality and safety of patient care. Most | | | | identification of quality core measures, decreased |
| clinical teams depend on physician documentation to | | | | medical errors in treatment and lesser risk in legal |
| identify the diagnosis and risk factors. However, such | | | | matters. However complex the diagnosis may be, with |
| documentation may be ambiguous, incorrectly stated | | | | superior documentation standards, the higher will be |
| or sometimes even missing. Many hospitals are now | | | | your reimbursements. CDI programs also defend you |
| recognizing the importance of a clinical documentation | | | | against RAC audit liability risk. |
| improvement program to lay emphasis on the value of | | | | Thus, a comprehensive clinical documentation |
| quality care and precise documentation. Clinical | | | | improvement program can bring about a drastic |
| specialists are being inducted into the clinical team to | | | | improvement in the overall efficiency of the hospital |
| give a new impetus to the documentation practice. | | | | and produce long term positive results. |
| A clinical documentation improvement program typically | | | | Every hospital needs to implement a clinical |
| begins with an assessment of your DRG based | | | | documentation improvement program in order to make |
| records and the documentation requirements. It helps | | | | the running of the hospital go a lot smoother. It always |
| identify quantifiable objectives for your CDI program. | | | | helps to keep clear record of things for future |
| The program manages every feature of CDI, right | | | | reference. |