Clinical Documentation Improvement (CDI) as a data management tool can play a vital role in record keeping and monitoring hospital operations. Most hospitals have in the past years seen the need to consider CDI as a measure of improving quality service delivery. Hospitals which have realized the significance of Clinical documentation improvement invest dearly on Clinical documentation specialists whose main duty is to help in the analysis of patient data records from the time of admission, recovery process and discharge. Unfortunately, most physicians have not wholeheartedly welcomed CDI claiming that the program only benefits the hospital while at the same time increasing workload. It is therefore critical to motivate physicians to appreciate, welcome and support CDI program for its benefits not only to the hospital but also to the physicians.
The hospital management staff must educate physicians on ways through which CDI program can ease their operations and ensure reputable quality service delivery. A workable documentation program is considered legible, complete, precise and clear to understand to avoid billing errors and errors associated with misdiagnosis that act as shortfalls to quality patient service delivery. In other words, Clinical documentation improvement enables physicians keep data records that conform to the quality standards and ethical guidelines of medical practice. To ensure effectiveness of clinical documentation improvement program, the hospital needs to; (1) identify the audience, for instance, academic physicians (2) engage clinicians in comprehensive CDI training (3) educate physicians on the benefits of CDI program prior to its implementation and finally (4) incorporate CDI within the clinicians' workflow.
Benefits of CDI Program
There are a number of significances of CDI inclusive of improved communication, eased recognition of co-morbid medical conditions that are responsive to treatment and validation of the care provided. CDI program maximizes reimbursement available through Medicare severity diagnosis related groups (DRG) system. CDI helps physicians maintain accurate documentation and demonstrate how such documentations relate to patient's clinical picture as well as financial aspects of the hospital. Accurately specified diagnoses are very crucial in the outpatient hospital operation system as in the inpatient system.
Every diagnosis must be specific and end result reporting must be as accurate as possible. This will impact hierarchical condition. Accurate clinical documentation enhances communication and facilitates quality reporting of patients' recovery progress. In a study aimed at realizing the of CDI, researchers considered metrics such as rates at which documentations were completed in every month, severity of illness (SOI), risks of mortality; all-payer refined DRG, as well as Surgical Care Improvement Program (SCIP) measures were assessed throughout the study (Reyes et al., 2017). Findings from this study indicate that there were comparatively significant improvements in quality metrics, coding and reimbursement after the implementation of CDI program. An 85% decrease in delinquent documentation in the surgical department was also reported in the aftermath of CDI implementation (Reyes et al., 2017).
Despite the benefits of CDI, it cannot be used in handling data relating to chronic medical illnesses like diabetes and high blood pressure (Saranto, 2014). Instead electronic health records (EHR) prove to be more effective in managing such data. However, with CDI completing medical records requires relative shorter duration as compared to electronic medical record (EMR) system. Clinical Documentation Improvement program is also recommendable as it can help reduce workload for clinicians (Saranto, 2014).
Clinical Documentation Improvement is a crucial tool to help physicians, nurses and healthcare providers within the hospital better recognize patient co-morbidities and physicians certain of the severity of their illnesses. This further ensures improved patient outcomes. An effective CDI program can also tighten the billing circle by slashing the number of cases discharged but have not received final billing because of unresolved queries related to coding. In other words, CDI speeds up the billing process without causing any structural alterations in coding process (Rollins, 2009). Smoothly run CDI program can provide better information that can be exploited for a number of purposes as well as promote cross-departmental collaborations between CDI and various review departments (Rollins, 2009). These review departments include; concurrent review, compliance review, and performance improvement efforts designed to better hospital operations.
Consequences of Failure to Implement Clinical Documentation Improvement Program
The main objective of any healthcare facility is normally to prioritize patient safety at all cost. This therefore means that failure to implement CDI program will negatively affect patient care service delivery. Not offering reliable quality healthcare services can in turn land the hospital on the wrong side of ethical guidelines that govern medical operations. Since the hospital is required to report and keep accurate and reliable patient documentation, failure to implement CDI program allows room for such unreliable data information to flourish. This may as well hinder the whole process of diagnosis which basically relies on documentation of patients' details.
CDI program is meant to facilitate coding for Diagnosis-related groups (DRGs) which are very crucial in conducting diagnosis especially in chronic illnesses. ICD-10-PC codes serve a vital role in medical operations as they are assigned to documented operating room (OR) or no-OR procedures normally conducted with patient's room, emergency or radiology wings (Green, 2018). Absence of CDI program translated to delayed or ineffective coding which may inconvenience the diagnosis procedure or delay procedures such as surgeries. Coders are required to note all conditions presented by a patient at the time of admission (Green, 2018).
Clinical documentation help physicians, healthcare providers and coders resolve any form of unclear, conflicting, missing or inconsistent data and ensure clarifications are obtained. The importance of proper documentations of patients' presentation helps in the billing processes (Green, 2018). It ensures that patients are not wrongly charged for mistakes resulting from physicians operations. For instance, in the case of surgery any form of fracture must be properly documented prior to commencement of the surgical procedure. Documentations indicating absence of fractures means that if any arises after surgery, it will be as a result of improperly conducted surgical procedure. Such aspects may not be accounted for in the absence of CDI program.
CDI program has proved to present several benefits that can help the hospital in its operations and reduce workload for physicians. Accuracy of data records is fundament for the hospital's objective of offering quality healthcare services to materialize. Maintaining accurate data records helps the hospital overcome some avoidable losses attributed to misinformation and poor communication. CDI also ensures that operations ethics are also adhered to and any physician or medical practitioner who breaches the ethical guidelines of observing documented diagnostic procedures accounts for his/her violations. For the objectives of CDI program to be achieved, physicians must undergo comprehensive training.
Green, M. A. (2018). Understanding health insurance: A guide to billing and reimbursement.Cengage Learning.
Reyes, C., Greenbaum, A., Porto, C., & Russell, J. C. (2017). Implementation of a clinicaldocumentation improvement curriculum improves quality metrics and hospital charges inan academic surgery department. Journal of the American College of Surgeons, 224(3),301-309.
Rollins, G. (2009). Clinical documentation improvement: gauging the need, starting off right.Journal of AHIMA, 80(9), 24-29.
Saranto, K. (2014). Nursing Informatics 2014. Fairfax: IOS Press.
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