Clinical documentation is at the core of every patient encounter. In order to be meaningful it must be accurate, timely, and reflect the scope of services provided. Successful clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle, and more important, to a healthy patient. To that end, CDI has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date.

A CDI program includes a myriad of people, processes, and technology that must work together to ensure success. Organizations need a well-rounded individual who can effectively articulate all the pieces: documentation requirements, code assignment, coding guidelines, and quality reporting.

CDI professionals come to the role from a variety of backgrounds, the two backgrounds seen most often are health information management (HIM) professionals and nurses. HIM professionals, through their education, are familiar with compliant documentation rules and regulations as well as accreditation standards that affect timely documentation. In addition, HIM professionals are also familiar with important areas such as privacy, security, and confidentiality that also impact sharing of clinical information. Nurses have a strong clinical background which helps them identify gaps in the clinical evidence and documentation. Both of these backgrounds provide a good foundation to become a CDI professional.

AHIMA is committed to advancing clinical documentation improvement (CDI) by providing education and training, certification, and other valuable resources to CDI professionals. Whether you are new to the CDI career, transitioning from a coding or clinical background, or an experienced CDI professional, AHIMA provides education and resources to support your lifelong learning and continued advancement.