Why you need to know about Clinical Documentation Improvement.

Clinical Documentation Improvement (CDI) is a process where clarity is sought from clinicians regarding ambiguous documentation in the medical record. CDI is designed to fill in the gaps in the documentation so that data is available for coding, overall patient care and quality measurement. [Buttner, P. 2014]

The majority of Australian hospitals already seek to clarify issues with the documentation through the querying process from coding departments. However, these queries are generated after the patient is discharged and this often places delays on the clinical coding process.

Best-practice CDI programs aim to seek complete, accurate and specific clinical documentation in the medical record during the patient’s admission rather than after the fact. Successful CDI programs appoint a CDI Specialist (CDS) to ensure the documentation fully reflects the patient episode of care. This process enhances patient outcomes and in turn enables complete and accurate coding and the allocation of an appropriate diagnosis related group (DRG). 3M are experts in training CDI Specialists so they make an immediate impact in their role. The return on the investment for this high quality training has proven to exceed customer expectations.

We are running three intensive training courses for the remainder of 2017. Places are limited so book now to register your interest.

CDI drives better input which has a flow on effect.

THE RESEARCH

53%

of clinicians think that CDI is very important to a hospital.

[3M ANZ research Feb 2017]

68%

Doctors are time poor, with 68% of residents already spending 4+ hours per day on documentation.

[Oxentenko, et al 2010]

3%

Only 3% of clinicians see the link between clinical documentation and accurate reimbursement.

[3M ANZ research Feb 2017]

#02

'Lack of understanding' was the #2 reason for clinicians not replying from the coding department.

0.00%

Zero medical courses at a tertiary level have formal teaching on clinical documentation.

THE SIDE OF CDI

Captures information that benefits patient outcomes

CDI helps drive accuracy and specificity of the diagnosis to ensure all important patient information is captured so clinicians have clarity and coders generate quality data.

Captures complexity which drives reimbursements 

Due to CDI capturing greater specificity, patients that reflect higher complexity through the coding process are typically reimbursed at a greater rate to address the increase in resources required to treat a more complex patient.

 Find Out More Today

The benefits of CDI are far reaching. To have one of our team get in contact with you or a colleague, please complete the form below. By filling the checkbox, you can also receive a copy of our whitepaper  "The Importance of Clinical Documentation Improvement for Australian Hospitals."

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