AHIMA book outlines principles for clinical documentation improvement programs

July 14, 2015

Clinical documentation is the foundation of every patient health record and a strong clinical documentation improvement (CDI) program is vital to providing meaningful information throughout a patient’s care.

A new American Health Information Management Association book, Clinical Documentation Improvement: Principles and Practicedefines CDI, explains its importance and outlines principles that can be applied in any healthcare organization’s CDI program.

Identifying the key users of clinical documentation – from patients to clinicians to coding professionals to reimbursement entities – author Pamela Carroll Hess, MA, RHIA, CCS, CDIP, CPC, explains how a strong CDI program affects them all.

“Clinical documentation is at the core of every patient encounter,” Hess says. “For it to be meaningful, it must be accurate, timely and reflect the full scope of the patient’s care. Successful CDI programs help facilitate the transfer of accurate information.”

The book addresses the fundamentals of clinical documentation, describes clinical documentation program implementation and recommends a process for growing and refining a clinical documentation program.

Key features of the book include:

  • How the transition to ICD-10 will have an effect on the CDI process, highlighting specific coding scenarios.
  • A chapter on critical thinking for physicians, nurses, clinical documentation specialists, and coders.
  • Extensive guidance on CDI program analytics and their importance to a sustainable program.
  • The latest on CDI technology solutions, an example query set, and work plans for CDI program implementation.
  • Additional guidance on CDI for APR-DRG and quality scoring.
  • Online appendices including an example presentation on physician education and engagement and strategy.

Sponsored Recommendations

Clinical Evaluation: An AI Assistant for Primary Care

The AAFP's clinical evaluation offers a detailed analysis of how an innovative AI solution can help relieve physicians' administrative burden and aid them in improving health ...

From Chaos to Clarity: How AI Is Making Sense of Clinical Documentation

From Chaos to Clarity dives deep into how AI Is making sense of disorganized patient data and turning it into evidence-based diagnosis suggestions that physicians can trust, leading...

Bridging the Health Plan/Provider Gap: Data-Driven Collaboration for a Value-Based Future

Download the findings report to understand the current perspective of provider and health plan leaders’ shift to value-based care—with a focus on the gaps holding them back and...

Exploring the future of healthcare with Advanced Practice Providers

Discover how Advanced Practice Providers are transforming healthcare: boosting efficiency, cutting wait times and enhancing patient care through strategic integration and digital...