The Importance of Accurate Clinical Documentation

CDI- Clinical documentation integrity is a job that has been quite often viewed as one that focuses on revenue and the reimbursement factor only. However, these CDI programs promote top accurate clinical documentation not only from the point of view of reimbursement, but also focusing on the quality of care provided to patients. All the important information in this health record is highly accurate, detailed and supporting greatly the medial decision-making. With the help of CDI implementation, healthcare professionals can access a detailed and accurate patient history anytime it is needed.

The healthcare matrix is huge, and patients circulate within this continuum from one healthcare facility to the other. Accurate clinical documentation plays an extremely important role, particularly considering the diversity of inpatient and outpatient settings. For example, the outpatient field can be even more complex that the inpatient one, comprising a variety of locations such as the ED (Emergency Department), different physician clinics, ambulatory surgery and also the services provided in a home care setting. Patients rely for good health on a vast number of physicians and healthcare settings. Since patients circulate, the healthcare professionals in any setting need instant access to accurate healthcare records. CDI programs offer comprehensive patient information with plenty of important and sometimes critical details that healthcare professionals need in order to make the correct treatment decision.

Also, when a patient is released from one hospital he will continue receiving care at another setting, perhaps at a physician’s clinic. Therefore, the new healthcare provider will heavily rely on the documentation available from the prior healthcare setting. This allows for a very good continuity in healthcare providing, so CDI programs play an extremely important role in the good workflow of things.

Accessing previous documentation, the new provider will also get better guidance for clinical decision making. CDI experts need to be highly aware of the overall impact of cdi across the healthcare matrix. The documentation available through cdi is always clear, consistent, reliable, highly legible, timely and precise. Precise documentation is exact and therefore it helps defining the exact health condition of the patient.