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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.

Physician Leadership and Physicians Ultimately a physician advisor(s), one from each service, who can provide advice, sponsorship, and promote the program among his/her peers and colleagues. Selected representatives from physician groups such as residents, hospitalists and consultant physicians to support the changes required.

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