Clinical Documentation Improvement (CDI) is the recognized process of improving healthcare records to ensure improved patient outcomes, data quality and accurate reimbursement1. The effects of having a good CDI program are multiple and they include excellent record keeping for future chart review, (especially beneficial in medical research and legal discovery processes), great communication amongst healthcare providers and better resource consumption and length of stay.
An essential part of the CDI process is the role of the Clinical Documentation Specialist (CDS). The CDS is usually a registered nurse (RN) who has specialized in documentation compliance and integrity. The CDS is trained to identify records that may be lacking the specific language needed to support the documentation standards as defined by insurance companies, research protocols and the legal system. The CDS will query the healthcare providers associated to the chart to look for clarification, avoiding at all times leading the healthcare provider towards a specific diagnosis.
The query is the way the CDS communicates with the healthcare provider. It is framed as a question with background information and a request for an action which is usually an agreement or a disagreement with the question. Queries are important because the help clarify terminology so that the medical record accurately reflects reality. The timeliness of a response to a query is very importance because the closer the gap in time between the generation of the query and the response, the more better the response will reflect reality.
The CDI program is usually enhanced by a physician advisor or medical director, who is in charge of advising the CDS, generating education processes and increasing compliance with the query answering process.
Marco A. Ramos MD
Second Medical Opinions PLC
Physician Advisor in Clinical Documentation
1. https://en.wikipedia.org/wiki/Clinical_documentation_improvement. Retrieved June 2, 2016
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