What is a Clinical Documentation Program?

CDI- or a Clinical Documentation program is a special program that plays a highly important role in the improvement of healthcare records. A cdi program helps ensuring that patients receive the right diagnosis and the right type of treatment. These programs help improving patient data quality, patient outcomes but they also play a major role in accurate reimbursement at the point of care. CDIs are basically hospital-based programs, but nowadays more and more physicians choose to implement these programs at their practices, because doctors acknowledge the importance and effectiveness of such cdi programs.

A cdi program has a major impact on overall organization and consistency of the medical records, and these programs are a true reflection of the clinical judgment and decision making of a physician. The main aim of a cdi program is to improve greatly clinical documentation and reimbursement. Efficient cdi program implementation will help minimizing claim denials which is an extremely important factor in healthcare. CDI programs result in better patient information and data and also medical records that are more useful.

The implementation of such a cdi program in your practice necessitates some planning, but it is definitely worth it. If you want to improve overall patient-physician relationship, improve documentation and create truly useful records, the best thing you can do is opt for such a cdi program implementation. It is a wise investment that you can make to improve the overall quality of care that you provide, and of course improve the reimbursement factor at your facility. CDI program implementation has a role not only in quality outcomes, but they also help reflecting a more accurate patient documentation which in turn will play a role in the integrity of the clinical and financial outcomes at your facility.

In order to create a truly successful outpatient cdi program, the following steps are needed:

• Gathering the data & assessing the current state
• Defining the scope and approach of the program-
• Outlining program goals and data requirements
• Determining the ROI (Return on Investment)
• Staffing infrastructure development
• Workflow + processes schedule
• Outlining a comprehensive communication plan – educating staff
• Setting performance goals
• Measuring. Tracking.
• Continuous evaluation of the program for even greater success