Clinical Documentation Improvement (CDI)

Clinical documentation improvement (CDI) “...is improving the quality of documentation to help ensure an accurate and complete reflection of the patient's care, comorbid conditions, and treatment- which impacts severity of illness (SOI) and risk of mortality (ROM)” (Custodio et al., 2013, p. 56 ). This is an important topic for health care facilities and physicians to ensure it is done well so that the quality of care, reimbursement and financial aspects are correct. “There are several other factors impacted by documentation, including present on admission (POA), hospital- acquired conditions (HACs), and patient safety indicators (PSIs). Some secondary diagnoses are considered complications/comorbidities (CCs) or major complications/comorbidities
This type of documentation error is one of the most common occurrences as a result of the transfer to electronic health records (EHR) (Chesire, 2013). The classic way of handwritten patient charts has had a long reputation of medical errors due to poor documentation based on physician handwriting. Indecipherable handwriting can cause major discrepancies in clinical documentation, which can lower the quality of patient care and therefore error (Chesire, 2013). With continual improvements of the EHR, the concern of illegible handwriting is no longer needed. The EHR has many benefits to clinical documentation compared to the older style of handwritten charts. If proficient in the use of the EHR, documentation time can be cut down, along with faster connection times to find and view health records (Zhang, Shubina, Morrison, & Turchin, 2013). They can also aid physicians in determining particular diagnoses or prescriptions as well as aiding in communication with other providers about said patient (Zhang et al., 2013). The EHR has many advantages to clinical documentation improvement, yet in some aspects the EHR lacks in proper
According to Aragon Penoyer et al. (2014), documentation is used for other things such as “evidence for medical legal cases, required backup for reimbursement, and information for developing measures for quality and regulatory purposes” (p. 131). The International Classification of Diseases coding system is used to “record diagnoses or the reasons for treatment or care…measure the quality, safety, and effectiveness of care; design payment systems; process claims for reimbursement; conduct research, epidemiological studies, and clinical trials; and set health policy” (Moczygemba & Fenton, 2012). The tenth revision of the system allows for more accurate reimbursement claims and provides a more convenient way of using the information from the records for research and data mining (Moczygemba & Fenton, 2012). The information coded comes from patient records; for that reason, it is extremely important for documentation to be