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.
Now, more than ever, CDI professionals are in high demand. By obtaining AHIMA’s Certified Documentation Improvement Practitioner (CDIP®) certification, professionals distinguish themselves as knowledgeable and competent in this field.
Learn more about the CDIP certification and resources to prepare for the exam.
AHIMA offers in-person and virtual meetings to advance the CDI profession, help CDI professionals enhance their skills and competencies, and provide guidance for those looking to enter this field.
August 1‒2—In Person: CDI Summit: Advancing the Documentation Journey
The premier CDI event of the year, AHIMA's CDI Summit consists of interactive, thought-provoking sessions, showcasing real world examples to stimulate discussion to provide critical insights into CDI program success and networking opportunities.
The activity has been submitted to the Texas Nurses Association for approval to award contact hours. Texas Nurses Association–Approver is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
August 3‒4—In Person: Certified Documentation Improvement Practitioner (CDIP®) Exam Prep Workshop
This extensive two-day workshop is designed to prepare the healthcare professional to sit for the CDIP examination by using real-world examples and learning activities to review the six domains covered in the CDIP exam: Clinical and Coding Practice, Leadership, Record Review and Document Clarification, CDI Metrics and Statistics, Research and Education, and Compliance.
October 15‒19—In-Person: 88th Annual AHIMA Convention & Exhibit
The premier annual event for health information brings together healthcare leaders, health information professionals, and other stakeholders from every segment of healthcare for industry updates, best practices, innovative ideas, insights from lessons learned, and to discuss how health information is shaping the future of healthcare as we “Inspire Big Thinking to Launch Our Future.”
November 2—Virtual: Certified Documentation Improvement Practitioner (CDIP®) Exam Prep
Prepare to earn AHIMA's highly-respected Certified Documentation Improvement Practitioner (CDIP) certification in your own time with this six-webinar series and live virtual chat. Each webinar reviews a domains covered in the CDIP exam: Clinical and Coding Practice; Leadership; Record Review and Document Clarification; CDI Metrics and Statistics; Research and Education; and Compliance. A virtual chat session is also offered for attendees to interact with experienced CDI professionals to gain test taking tips and advice.
Clinical Documentation Improvement (CDI) Academy: Inpatient and Outpatient Best Practices
2017 dates and locations will be announced November 2016.
This comprehensive program covers both inpatient and outpatient settings, creating a larger return on investment for participants. Consisting of an introductory webinar, a publication, and a three-day in-person meeting, the Academy provides CDI best practices to those working in the CDI field and suggests paths for those looking for a career change or enhancement (including coding professionals, transcriptionists, nurses, physicians, and others).
The Academy’s unique content is interactive with real-life examples and exercises designed to encourage discussion and active learning and is broken into tracks to support CDI professionals from different backgrounds. The clinical basics track focuses on clinical evidence, pharmacology, and pathophysiology. The coding basics track does a deep dive into both the inpatient and outpatient Official Coding Guidelines.
There are also tracks for new and experienced CDI professionals. The track for new CDI professionals has a focus on how to perform a thorough record review, identify gaps in the documentation, and how to write compliant queries. The seasoned CDI professionals have a track that teaches advanced CDI opportunities.
Clinical Documentation Issues
This six-lesson course introduces professionals to the important skills and areas of knowledge that will assist them in becoming successful clinical documentation specialists.
Clinical Documentation Improvement: Program Success
This six-lesson course reviews overall aspects of managing a clinical documentation improvement program, including planning and organization, monitoring and evaluating, and hiring and retaining qualified staff.
Clinical Documentation Improvement: Quality Measures and Documentation Standards
This six-lesson course reviews how CDI programs relate to quality measures, and how CDI affects documentation necessary to meet industry standards, as well as report cards.
Recognize ICD-10 Documentation Requirements
This six-lesson training course provides information on the terminology utilized in ICD-10-CM/PCS that impacts clinical documentation.
AHIMA also offers a series of professional development courses to help professionals add valuable skills to their toolkit.
This course provides information and skills needed to develop and maintain a sense of professionalism by analyzing the connection between ethics and professionalism and discussing other important factors related to professionalism, including workplace goal setting, time management, interpersonal skills, workplace communication skills, and conflict management.
Effective Time Management
This course provides an overview of time management skills, concepts and techniques. Participants will learn strategies for maximizing personal effectiveness, including organization, delegation, and the proper use of technology.
First Line Supervision and Leadership
This course provides an overview of general supervision concepts and methodologies by helping understand requirements for making the transition to first-line leadership, and introducing the paradoxes of first-line supervision. The student will examine the role of a supervisor, qualities of an effective leader, and develop strategies for effective communication, management, and training.
Finance and Accounting For Non-Financial Managers
This course provides an overview of the principal areas of financial management by introducing financial terminology, relating financial measures to operating information, and enabling understanding and application of these measures to operating performance.
This course offers students the skills necessary to interpret and critically evaluate statistics commonly used to describe, predict, and evaluate data in an information driven environment. The focus is on the conceptual understanding of how statistics can be used and how to evaluate statistical data.
This introductory level course presents a variety of topics essential to the development of critical thinking skills by introducing concepts essential to the comprehension, analysis and creation arguments: induction, deduction, informal fallacies, Aristotelian and symbolic logic, modes of persuasion, perspective and bias, language and meaning, culminating in the development of reasonable strategies for belief information.
This course assists in establishing a positive and proactive career mindset early and consistently in academic process to help ensure career compatibility and success. Topics include personalized career assessment, enhancing transferable career skills, developing a personal career brand, and career position seeking skills.
Communication Skills For Managers
This course provides an overview of effective methods of communication for managers. Students gain a working knowledge of the difference between hearing and listening, and will apply strategies for improving listening, speaking, and writing skills. In addition, students will examine methods of delivering criticism, asking questions, and teaching someone a process. The course also covers how to create effective business communications, such as presentations and documents.
How To Manage Conflict in the Organization
This course provides an overview of the effective ways to manage conflict in the workplace. It identifies types of conflict and provides techniques for eliminating conflict by examining the different types of conflict resolution and identifying differences between interpersonal and structural conflicts in the workplace.
Interpersonal Communication Skills in the Workplace
This course an overview of the principal area of interpersonal communication by introducing the importance of effective interpersonal communication in the workplace and examining the key skills and methods related to workplace communication. Participants will learn how to successfully present ideas and information as well as listen to others' ideas to solve problems.
AHIMA is the publisher of the world’s most respected, technically accurate, and widely used books in the health information management (HIM) field.
AHIMA members, educators, and healthcare professionals prefer AHIMA books because they know they can count on our authors to provide the highest levels of expertise and the most up-to-date knowledge available.
Clinical Documentation Improvement: Principles and Practice
Identifies the fundamentals of clinical documentation, how to implement a CDI program, and how to grow and refine an existing program.
Documentation for Health Records
This publication addresses health record documentation requirements and practices, issues related to paper and EHRs, and offer an applicable orientation and overview of healthcare documentation.
Documentation for Medical Practices
Discover solutions for the unique needs of medical practices with chapters on health record content, accreditation standards, risk management, liability, consumer-driven implications, as well as reimbursement considerations, regulations, and policy.
Certified Documentation Improvement Practitioner (CDIP®) Exam Preparation
Clinical documentation improvement (CDI) competencies are becoming more valued in healthcare professionals of all kinds, including health information management (HIM) professionals, nurses, and physicians. Test your knowledge of these concepts and prepare to sit for AHIMA's Certified Documentation Improvement Practitioner (CDIP®) examination with this guide, which includes two full exams comprised of 280 total questions.
Pack a lot of learning into one hour with AHIMA webinars.
July 26—Encephalopathy: When Altered Mental Status Doesn’t Make Sense!
This webinar discusses the clinical differences between altered mental status, confusion, delirium, and encephalopathy. The audience will understand the pathophysiology and etiology of each clinical process and be able to identify common clinical indicators related to each process. Examples of cases illustrating the clinical application of the different types of encephalopathy will be presented in addition to presenting structured physician queries to help attendees to communicate more effectively with the physicians regarding documentation of these complex clinical issues. Additionally, the presenter will discuss the correct coding of encephalopathy in ICD-10-CM.
August 4—Leading Your CDI Program to Become a Strategic Force within Your Organization
This presentation will provide critical information and strategies for building a high-performance team, translating data into actionable reports, taking a multifaceted approach to communication, identifying initiatives for improving hospital metrics, and seeking opportunities for collaboration.
August 23—An Auditor’s Viewpoint: An Inside Look at Audit Processes and Strategies
With the increasing amount of audits, accurate documentation is no longer just about clinical care quality; it is also key for organizations to alleviate audit risk. The more organizations understand audit requirements the better prepared they will be to avoid denials and proactively prepare for audit appeals. This presentation will include an auditor’s viewpoint in the processes, key players and trends related to audits, and the impact for healthcare providers. The presenter will explore the audit landscape by identifying different types of audits and sharing best practices for an effective audit program to ensure compliant documentation, reduce audit risk and achieve revenue and margin integrity for overall strong financial performance.
September 20—CDI and Coder Collaboration—Maximizing Documentation Quality and Revenues
ICD-10 is a new language for both providers and payers, and the two teams—CDI specialists and coders—will work most effectively by mastering ICD-10 documentation and coding rules together. Facilities that already have strong CDS-coder collaboration put themselves in a position to maximize clinical documentation quality and revenues in an ICD-10 environment. A thorough ICD-10 education will empower CDI staff to educate providers to ensure clinical documentation quality and appropriate reimbursements.
On Demand Webinars:
Coding and Physician Self-Defense: A Live Presentation to the Medical Staff
This webinar discusses physician profiling, payment, and patient care issues related to documentation of the inpatient health record. Subsequently, clinical examples will be presented and broken out by the components of a DRG which helps physicians understand how improved documentation allows for the physician to realize their optimal performance profile and payment and how the documentation process is enhanced by constructive communication with CDI personnel and coding staff.
Quality Measurement: Health Information Management’s Connection to Value-Based Purchasing and Compliance
In the future, hospitals will no longer be paid based on the volume of services provided. This is the concept behind value-based purchasing (“VBP”). Hospitals now must focus on both (a) coding for appropriate reimbursement; and (b) coding for accurate quality measurement. This requires providers to offer and document evidence-based, patient-centered treatment.
Writing Effective and Compliant Physician Queries
This presentation will offer advice on how to construct queries that provide more effective communication with the physician and how to avoid denials and potential coding abuse allegations by external reviewers.
CDI Stepping Beyond Fee For Service
Capturing patient severity and acuity is critical to quality scores and outcomes measures. This webinar takes a look at other elements and systems like APR-DRGs and risk adjustment used to measure and considers your CDI success.
The Top 20 ICD-10 Documentation Issues that Cause DRG Changes
This webinar examines the top 20 documentation issues providing the cause and mitigation for the shift, and the resulting outcome. Attendees will learn strategies for determining other DRG changes, including how to determine the top MS-DRG for an individual hospital, and how to look for opportunities to improve documentation, including templates.
Using CDI To Improve Quality Reporting
Attendees will learn how interpreting coded data and clinical documentation for quality reviews and reporting is expanding the role of CDI professionals.
Coding and Clinical Documentation Improvement with a Technology Backbone
CDI specialists can dramatically enhance productivity, while successfully impacting physician documentation practices within the EHR in a staffing neutral environment. This webinar shows how to improve coding and clinical documentation with a technology backbone.
CDI and ICD-10-CM Documentation Tips
This webinar provides a look at documentation specifics within the ICD-10-CM code set. AHIMA’s ICD-10 Documentation Tips resource will also be reviewed with the audience.
Physician Engagement For CDI
This session provides a review of the guidelines in chapter 19 and 20 of ICD-10-CM, and the correct use of seventh characters. Cases in this webinar challenge the participant to use critical thinking skills to take a closer look at documentation.
Evolving and Adapting the Changing Role of the CDI Professional
CDI is moving into other areas of healthcare and is focusing on all payers and patient types. The webinar will help guide the CDI professional (or aspiring CDI professional) to evolve and adapt to the changes, including the transition to ICD-10.
AHIMA offers a number of resources to assist organizations, CDI professionals and those interested in a career in CDI.
HIM Body of Knowledge™ Online Library
Monthly Blog: Documentation Detective
Infographic: The CDI Journey
Practice Briefs and Toolkits Member only resource; join during July and save $30 on your membership
Join AHIMA as we celebrate Clinical Documentation Improvement Month during July and enjoy discounts on select CDI products!
The CDI Month brochure below highlights special offers on CDI products during July, CDI resources, and more.
CDI Summit: Advancing the Documentation Journey
Save 18% when you register by July 21
August 1‒2 l Washington, DC
Purchase AHIMA's NEW Certified Documentation Improvement Practitioner (CDIP®) Exam Preparation book during July and receive a 25 percent discount on the CDIP exam when you register by November 15, 2016.
Sharon Easterling, MHA, RHIA, CC, CDIP, CPHM, FAHIMA
Price: $79.95 | Member Price: $64.95
Product #: AB300615
Certification: Certified Documentation Improvement Practitioner (CDIP®)
Now more than ever, a strong, highly respected clinical documentation improvement (CDI) program can make a difference in achieving the goals of RAC audits, ARRA/HITECH, and other important initiatives aimed at improving the quality of healthcare.
Professionals earning the CDIP® credential will:
Download the CDI Month brochure to learn how you can take advantage of great savings this month.
PLEASE NOTE: All CDI Month discounts are available only on purchases made during the specific time periods indicated. Discounts cannot be applied to past purchases.