Medicare Compliance & Reimbursement - 2018 Issue 2
CDI: Sharpen Your CDI Skills With These Handy Strategies
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Article Overview
This article covers practical clinical documentation improvement (CDI) concepts discussed in a webinar setting, including documentation templating ideas, staff education, EMR accuracy, and implementation oversight. It is aimed at professionals involved in CDI, coding, compliance, and documentation workflow improvement who want to understand broad strategies for strengthening documentation quality and review processes.
Why This Topic Matters
It helps readers understand the main CDI topics that can affect documentation quality, compliance readiness, audit defensibility, and operational efficiency without needing to read the full premium article.
Article Sections
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Master These Unique Clinical Documentation Concepts
Introduces documentation concept categories discussed for improving clinical record completeness and consistency. The section focuses on broad CDI and coding workflow concepts across diagnosis and procedure documentation.
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Education is Key Element to CDI Success
Explains the role of training and workflow support for staff involved in documentation capture and CDI processes. It also addresses how education can support broader operational goals.
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Make Sure EMR Info is Accurate, Timely
Covers concerns related to electronic record dependency, information carried forward, and the need to review documentation for current accuracy. The section emphasizes audit awareness and meaningful encounter documentation.
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Pose These Vital Questions to Stay Accountable
Presents a set of implementation and oversight questions for evaluating tools, processes, and staff readiness. The section also addresses the importance of compliance and audit planning.
What You Will Learn
- How CDI concepts can be organized to support documentation quality
- Why staff education matters in documentation workflows
- What issues can arise when information is carried forward in an EMR
- Which broad questions to consider before adopting a new documentation process
- How audit oversight fits into CDI and workflow improvement
Who Should Read This
- Clinical documentation improvement specialists
- Medical coders
- Compliance professionals
- Physician practices
- Healthcare operations staff
- Coding and documentation educators
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