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AN ESSENTIAL GUIDE TO CLINICAL DOCUMENTATION …

AN ESSENTIAL GUIDE TO CLINICAL DOCUMENTATION IMPROVEMENT White Paper Written by A. Jamal, MBA, CHIM & C. Grant, CHIM & K. Myrick, RN 1 An ESSENTIAL GUIDE to CLINICAL DOCUMENTATION Improvement Written by A. Jamal, MBA, CHIM & C. Grant, CHIM & K. Myrick, RN What is CLINICAL DOCUMENTATION Improvement (CDI) and Why is it Important? Because CLINICAL DOCUMENTATION is at the core of every health care encounter, it must be complete, precise and reflective of the full scope of care and services provided. Increasingly, this DOCUMENTATION , as well as the resultant data and information extracted from that DOCUMENTATION , is how providers and organizations are being measured and adjudicated.

improving documentation. The CDI Specialist A key aspect of the CDI program is to review documentation in a chart from a clinical perspective, keeping in mind disease processes, symptomology, and appropriate treatment. Physician documentation is often noted in clinical terminology, not always listing the diagnostic equivalent.

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