Clinical Documentation Improvement (CDI)

Clinical Documentation Improvement is the process of improving clinical documentation at all points of care by all clinicians to support safe care, communicate critical clinical information and enable accurate clinical coding and funding outcomes.

Clinical Documentation improvement is aimed at improving the integrity of clinical information to accurately reflect the clinical truth of an episode of patient care. This course is available in 2 streams: a) clinicians Stream and; b) Healthcare leaders and admin stream

Target Audience: 

• Clinicians (doctors and nurses), Healthcare Admins, Practice Managers, Doctors, Clinical Coders, Medical transcribers, Patient liaison officers, medical billers, hospital legal department officers, medical insurance officers, claims submissions processors.

Prerequisite: 

• Good command of English Language

Key Takeaways

• CDI with a CDR process is a necessary role in any health organization to ensure correct data capture and safe care. This role needs to be performed in some capacity whether as part of coding or by a designated professional.

• A combination of education approaches are recommended to embed improved documentation in daily practice.

• The success of the concurrent documentations review process is reliant on consideration of many factors, including thorough assessment of existing documentation systems, impact on clinical and coder workflow, mode of query and a reliable feedback mechanism.

• A mix of responsive engagement strategies and executive support is essential to the success and sustainability of a clinical documentation improvement program

• A CDI Program undertaken by a multidisciplinary team overseen by an experienced Health Information Manager is recommended to ensure the success of this portfolio.

Course Structure

This course is delivered self-paced. It is comprised of instructor led video lectures with interactive short quizzes to test your knowledge as you and a final test to examine the knowledge gained form the course. This course is available to be completed within 90 days from registration date.

• 20 CPD / CME Hours

In collaboration with:

• The Coding Academy