What does 'clinical documentation improvement' (CDI) aim to accomplish?

Clinical documentation improvement (CDI) focuses on enhancing the quality of clinical documentation within healthcare settings primarily to ensure accurate coding practices and proper reimbursement. Improved documentation helps capture the full scope of patient care, reflecting the severity and complexity of conditions treated. This accurate and detailed documentation is essential not just for financial reimbursement from insurers, but it also plays a crucial role in compliance with regulatory standards and contributes to the overall quality of patient care data.

The enhanced documentation facilitates better communication among healthcare providers, aids in quality reporting initiatives, and supports better clinical outcomes by providing a more comprehensive view of the patient’s status, treatments rendered, and their responses. When documentation is clear and comprehensive, it helps ensure that all clinical services provided are appropriately reported and that healthcare organizations receive the correct reimbursement for those services.