Assignment:
Policy on Clinical Doc Improvement
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, and 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. Alternatively, you may research policies, guidelines and standards on CDI on your own to use as a benchmark. Then create a facility policy on Clinical Documentation Improvement.
Include at minimum: use the templet attached
a. CDI initiative requirements (the goal of the program)
b. Describe the qualifications of a professional CDI specialist
c. Process steps for CDI
d. Communication process between physician/provider and CDI specialist
e. Identify the types of accounts included in the CDI process
f. CDI query form, on a separate page from the policy.
The completed CDI policy should be 2pages. Create your own policy, do not copy from a resource and clearly identify all resources used for the policy creation.
Requirement
Policy includes CDI initiative requirements.
Includes policies on querying the physicians.
Identifies categories of patients to be included.
Applies correct spelling, grammar and a consistent policy format
This week focuses on clinical documentation improvement (CDI). Let me tell you, this is a HOT topic in HIM. Many organizations are looking for individuals that specialize in CDI and are paying big bucks for the right one! The reason is that quality documentation in the healthcare record is very important. Think about how documentation also serves as communication among providers, evidence in court, a means of gathering data, etc. The healthcare organization relies heavily on clinical documentation.
As HIM professionals, we understand that coders also rely on documentation in records to ensure accurate codes. Sometimes, coders are expected to query doctors if documentation is not clear for coding. It is important that coders understand how to query the physician without leading them to a diagnosis.
You will continue your policies this week with a policy on CDI initiatives. Be sure to include in your policy characteristics of a good query form (see assignment directions for details). You can use the Benchmarking Resources under module 1 or perform your own research for this policy.
Attachment:- Benchmarking Resources.rar