CDI stands for "Clinical Documentation Improvement," which is a specialized process focused on enhancing the quality and accuracy of medical records. It involves various approaches and strategies to ensure that clinical documentation in healthcare settings is comprehensive, detailed, and reflective of the services provided to patients. The main objective of CDI is to facilitate better communication between healthcare providers and to capture a complete and accurate patient story for maximum patient care, effective reimbursement, and appropriate data reporting.
CDI professionals typically work alongside healthcare providers, coding specialists, and other stakeholders to identify and rectify any gaps or deficiencies in medical documentation. They review medical records and interact with healthcare staff to clarify and obtain missing or unclear information related to patient conditions, procedures, and services rendered. By doing so, CDI specialists help to reduce the likelihood of coding errors, complications, and adverse events, leading to improved patient outcomes.
Furthermore, CDI processes also serve the purpose of optimizing accurate reimbursement for healthcare facilities. Accurate documentation enables appropriate coding, resulting in correct diagnosis-related groupings (DRGs), which ultimately determine reimbursement levels for services provided. CDI professionals play a crucial role in ensuring that documentation supports the severity of illness and intensity of care provided to patients, thereby aiding organizations in optimizing their reimbursement revenue.
Overall, CDI contributes to improved patient care, accurate healthcare data, and financial stability for healthcare organizations, promoting better overall healthcare delivery.
