CAREER STEP CLINICAL DOCUMENTATION IMPROVEMENT EXAM WITH VERIFIED FOR ACCURACY

Clinical Documentation Improvement Organizations strive to continuously improve their clinical documentation through organized clinical documentation improvement (CDI) programs (realizing that strong CDI program means hiring and training skilled CDI specialists). The purpose of a CDI program is to perform reviews of documentation for conflicting, incomplete, or nonspecific provider documentation. These reviews can be done in a concurrent and retrospective manner, with reviews usually occurring on the patient care units. These types of programs are designed to improve documentation, coding completeness, reimbursement, and severity of illness in the classification process. A variety of individuals may perform this function, but it is commonly assigned to health information management (HIM) professionals, coding professionals, physicians, nurses, and other professionals with a clinical and/or coding background. Certainly good communication with the pro Brainpower Read More imgMap communities home adv srch contact help Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS Editor's note: This brief replaces the 2001 practice brief "Documentation Requirements for Acute Care Inpatient Records." The brief was updated December 2014 with new ICD-10-CM/PCS implementation date. The United States will