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Getting started with Clinical Documentation Integrity (CDI) 

By: Melanie Endicott, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CCS-P, FAHIMA Senior Director, International Education and Training

Clinical Documentation Integrity, otherwise known as CDI, is at the center of everything we do as health information professionals. As healthcare organizations become ever more reliant on data and the flow of data, you and your team need to take the time to understand the core elements of an effective CDI program. Quality care and timely reimbursement start with high quality clinical documentation.

What Exactly is CDI? 

  • A continuous improvement process that helps toenhance documentationand reduce reimbursement issues, such as denials. 
  • Ainterdisciplinary communication processthat unites departments and organizations. 
  • An analytical discipline that yields valuable insights for improved patient care. 

As a health information professional, you draw upon a comprehensive understanding of clinical data to ensure that health information is always accurate and trustworthy. 

Critical to this work, clinical documentation remains the foundation of every health record in every setting. Patients, physicians, health plans, regulatory bodies, and healthcare organizations recognize the need for accurate, timely and consistent documentation. Data integrity is essential for making decisions about patient care and the appropriate use of health information. 

Build Independence and Initiative into Your Organization’s CDI Program 

CDI is a comprehensive, multi-disciplinary, hospital-wide effort to incorporate the terminology needed to accurately translate a patient’s condition into precise codes. Any organization—small and large—can make improvements here.  

As the Senior Director of International Education and Training at AHIMA International, we have partnered with organizations to initiate effective CDI programs that have a direct impact on patient care by providing accurate and timely data. At AHIMA International, we've helped organizations successfully implement CDI practices that drive improvements in the revenue cycle.  Dr. Sarah Sebai, CFO for Al Ain Hospital, UAE says ''By partnering with AHIMA, we launched a clinical documentation integrity (CDI) initiative. Working closely with our clinical and revenue cycle management teams, we were able to achieve an improvement in the case mix index (CMI) by 16% and an increase in claims resubmission success rate to 90%.” 

Getting started with CDI 

AHIMA International offers a comprehensive CDI workshop where you can learn best practices from around the globe and earn 4 CEUs.  

CDI Principles Workshop Learning Objectives 

  • Evaluate the need for a CDI program within your facility 
  • Learn to write effective and compliant queries 
  • Foster an atmosphere that encourages physician engagement and executive support 
  • Lead the development of CDI metrics and dashboards 
  • Develop policies and procedures to manage denials 

Join this on-demand workshop today, exclusively created for those who live/work outside the U.S. and increase your knowledge and understanding of CDI to create quality health information.  For questions and inquiries about training your organization in CDI, contact AHIMA International at internationalinfo@ahima.org

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