Clinical Documentation Improvement

Improving the quality of coded data is necessary, but clinical documentation also requires attention.  The implementation of a Clinical Documentation Improvement Specialist (CDIS) program is an initiative to provide this.

A CDIS program should aim to improve the quality of clinical documentation, reduce patient harm and ensure episodes of care are coded to reflect the true complexity.

Episodes of care that are reflective of resource utilisation enables enhanced service planning; accurate data collection; clinician engagement; improved communication; quality and safety outcomes; reduced coding turn around and adequate funding of services rendered.

Ideally, the CDIS team are based on inpatient wards, but work alongside & within the clinical coding team to lead, plan and deliver initiatives to reduce clinical documentation vulnerabilities and ensure compliance with documentation standards.

A CDIS program will increase clinical engagement & clinician confidence in data, which is often, arguably, the most important but difficult to measure.

Once bedded down, local CDI specialists will become involved in assisting with the review of Hospital Acquired Complications (HACs), initiatives aimed at leading better value care and (where appropriate) the organisations digital health development.  They are a unique position to monitor the data and trends before an issue is identified.

Clare Collinge

For more information please contact Linda Westbrook