In the latest resource on the CDIA Community, Community member and Clinical Documentation Specialist Fatimah Al Hussain from John's Hopkins Aramco Healthcare shares her research paper:
How clinical documentation improvement program (CDI) can affect quality, patient safety outcomes and increased reimbursement: a systematic review.
Abstract
Background: Clinical documentation improvement (CDI) reviews medical record documentation for completeness and accuracy. With the help of this program, hospitals can change their clinical documentation culture. The basic idea behind CDI is to include clinicians in improving clinical documentation in "real-time" to suit reporting, analysis, and reimbursement.
Methods: The study uses a systematic review design following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure the systematic review is conducted transparently and replicable.
Results: The study analyzes eleven previous pieces of literature in the area, with four examining the impact of CDI on healthcare quality metrics and two investigating the profitability of proper documentation. Another two study investigates the relationship between CDI and the severity of an illness, medical coding, and hospital reimbursements. Two studies present case studies comparing the use of CDI in developed and developing states. Another study reveal that CDI is crucial in medical coding, as many practitioners reported issues with inadequate documentation and inconsistent diagnoses.
Conclusion: The systematic review notes that clinical documentation integrity has numerous advantages for the quality of care received, patient safety, and hospital revenue and reimbursements. However, CDI implementation still lags in some developed and most developing countries. Healthcare institutions should improve staff training, review documentation, improve hospital technology, and use continuous monitoring and evaluation.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact community@cdia.com.au to learn more.