Create A Facility Policy On Clinical Documentation Improveme

Create a facility policy on Clinical Documentation Improvement (CDI)

As with other organizational policies and procedures, policies on clinical documentation improvement (CDI) will improve communication and promote a successful, organized process. Clinical documentation improvement has the goal of complete and accurate health record documentation that reflects the actual care and treatment provided during a healthcare visit, appointment, or stay. It is commonly executed via queries to the physician/provider that seek clarification or expansion on documentation that has been recorded in the medical record by that physician/provider. After the documentation is then concluded via the CDI query process, the patient record is forwarded to coding so that coding is completed after documentation is finalized in the CDI process.

To prepare the CDI policy, locate policies, procedures, and guidelines provided for benchmarking in Module 01 under Benchmarking Resources. Alternatively, research policies, guidelines, and standards on CDI to use as a benchmark. Then create a facility policy on Clinical Documentation Improvement. Include at minimum: CDI initiative requirements (the goal of the program), describe the qualifications of a professional CDI specialist, process steps for CDI, communication process between physician/provider and CDI specialist, identify the types of accounts included in the CDI process, and CDI query form on a separate page from the policy. The completed CDI policy should be 1 page. Create your own policy, do not copy from a resource, and clearly identify all resources used for the policy creation. Benchmarking against other organizations' policies or available guidelines is essential in developing or revising policies and guidelines for a healthcare organization.

Paper For Above instruction

Create a facility policy on Clinical Documentation Improvement CDI

Facility Policy on Clinical Documentation Improvement (CDI)

Purpose

This policy establishes the framework for clinical documentation improvement (CDI) within the facility to ensure complete, accurate, and compliant health records that accurately reflect the care provided, thereby enhancing patient outcomes, coding accuracy, and reimbursement processes.

Scope

This policy applies to all healthcare providers, CDI specialists, coding staff, and related personnel involved in the documentation and review of patient records.

Objectives and Goals of CDI Program

  • To promote complete and precise clinical documentation that accurately reflects patient care and services rendered.
  • To improve documentation quality for optimal coding and billing accuracy.
  • To support compliance with regulatory requirements and accreditation standards.
  • To facilitate meaningful data collection for quality improvement and research.

Qualifications of CDI Specialists

CDI specialists must possess a relevant health information management credential, such as RHIA or RHIT from AHIMA, or equivalent clinical background. They should demonstrate knowledge of medical terminology, anatomy and physiology, coding guidelines, and healthcare regulations. Continuing education and experience in clinical documentation, coding, or health information management are essential for competent performance.

Process Steps for CDI

  1. Identification of accounts: The CDI team reviews patient records flagged for potential clarification based on predefined criteria, including complex cases, high-risk conditions, or discrepancies.
  2. Review of documentation: CDI specialists analyze the documentation within the record for accuracy, completeness, and compliance.
  3. Query initiation: If clarification or expansion is needed, the CDI specialist formulates a query using a standardized query form.
  4. Communication with providers: The query is sent to the responsible physician/provider through approved channels, such as secure messaging or documentation systems.
  5. Provider response and documentation update: Physicians/provider respond to queries, clarify, or add necessary detail to the record.
  6. Record review and finalization: The CDI specialist reviews provider responses and ensures documentation adequately reflects clinical facts before forwarding to coding.
  7. Coding and billing: The finalized record is sent to coding for accurate code assignment, followed by billing processes.

Communication Process

Effective communication is pivotal; queries are to be clear, concise, and non-leading. The CDI specialist maintains documentation of all queries and responses. Providers are encouraged to respond promptly, ensuring that clarification is documented within the medical record, which supports accurate coding and billing.

Types of Accounts Included in CDI

  • Inpatient hospital stays
  • Outpatient procedures and visits
  • Emergency department encounters
  • Ambulatory surgical procedures

CDI Query Form (Sample)

Patient Name Medical Record Number Date of Service Provider Name Query Date Query Type Query Details Provider Response
Clarification/Expansion

Note: This form is a sample template and may be customized per facility requirements.

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