Policy on Clinical Documentation Improvement

As with other organizational policies and procedures, policies on clinical documentation improvement (CDI) will improve communication and promote a successful, organized process. Clinical documentation Improvement has the goal of complete and accurate health record documentation that reflects the actual care and treatment provided during a healthcare visit, appointment or stay, and it is commonly executed via queries to the physician/provider that seek clarification or expansion on documentation that has been recorded in the medical record by that physician/provider. After the documentation is then concluded via the CDI query process, the patient record is forwarded to coding so that coding is completed after documentation is finalized in the CDI process.