Clinical Documentation
Clinical Documentation Improvement (CDI) is a process used in hospitals whereby nurses and/or specialists review clinical documents and provide feedback to physicians. The communication to physicians is utilized to aide in complete and accurate documentation. The documentation will address questions about coding, quality measures and overall care management of a patient. Process improvement initiatives are utilized to close the gap between coders and Clinical Documentation Specialist utilizing, ICD-10 International Statistical Classification of Diseases and Operations and Clinical Terms. Real-Time reviews and real-time query processes also becomes a part of the process improvement initiative.
- Process Improvement
- Communication Enhancement
- Query Process
- Real-Time Reviews