Clinical documentation is an extremely important aspect of inpatient care at hospitals, clinics, and even private offices. Medical documentation needs to be extremely clear, concise, and precise. Physicians rely on such clinical documentation in order to interpret different diagnostics and to accurately and efficiently prescribe treatments, and medications. Outpatient CDI is a highly important aspect, and such CDI programs help with an accurate representation of the patient’s medical status at any given point.
The coded data will then be translated into important reporting, and public health data, and of course such data is used for reimbursements and also for healthcare research. Outpatient CDI also helps physicians make well informed decisions regarding treatments, diagnoses, effective changes to different treatments (such as the prescription of different medications), and so on.
CDI can also be regarded as an AI (Artificial Intelligence) tool that helps physicians and healthcare providers, in general, stay up to date with patient records at all times. Clinical documentation is basically a set of medical information entered in a medical record in order to create a patient health information record. Typically, this information or the entries are authored by a healthcare professional (such as a dentist, a surgeon, or any other physician). It is extremely important to keep in mind that there are certain accreditation requirements and regulations as to who is allowed to record such information into the database.
CDI – Clinical Documentation Improvement specialists often have medical and clinician coding backgrounds. When discussing clinical documentation in the context of CDI, this generally refers to the given entries that are made by healthcare providers (this could be the main provider or a staff member) and he is the person responsible for the care of the patient during the office visit/ hospital admission.
CDI programs have been present in the healthcare field for a very long time, but they started getting more attention in the last decade. Over the years, hospitals around the globe realized just how important accurate diagnosis code reporting is and how this plays a major role in effective reimbursement. CDI has transformed from a trend into a necessity, with great emphasis on accurate billing for the healthcare establishment.