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The field of clinical documentation improvement (CDI) is emerging alongside the need for more accurate health care information that is reflective of the health status of Canadians. Health information management professionals and physicians play a critical role in the collection, transformation, protection, and distribution of clinical documentation. The quality of health data is dependent on the physician’s specificity in clinical documentation of patient health records, as this information is converted into data by coding specialists. Coded medical information, and associated hospital data, provides information surrounding patient severity of disease, a hospital’s expected length of stay, and a hospital’s mortality rate. Therefore, it is a physician’s responsibility to present accurate, comprehensive health documentation using terminology that can be recognized by medical coders. This guide highlights the benefits of CDI programs and the importance of physician documentation in the production of accurate and reflective healthcare data. An overview of the key terms used by medical coders based on the standardized CIHI coding methodology (version 2018 ICD-10-CA and CCI) is provided. Moreover, the effectiveness of the application of a CDI program is demonstrated through various real-life examples of outcome metrics, which can be impacted by the quality of clinical documentation. Improved health data can be achieved through implementation of a CDI program, with the main goal of achieving increased specificity and accuracy in clinical documentation, completed by clinicians. Implementation of a successful CDI program comes with benefits for physicians, medical coders, hospitals, health care organizations, and the patients. The engagement of physicians is integral in the success of a CDI program and can be efficiently achieved through involvement of key physician stakeholders, termed ‘physician champions’. In the long-term, clinical documentation improvement can ensure accurate and complete patient health information, benefitting the lives of Canadians today and into the future.

Previous Versions

Feb 25 2022
Feb 25 2022