Overview And Description Of Clinical Documentation...

Overview and description of Clinical documentation Improvement The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record. The CDI involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. The main focus of clinical documentation improvement is to enhance the clinical clarity of the health records which usually is practiced by the health information management (HIM) professionals, registered nurses, and a large group of other clinically oriented personnel (AHIMA, 2015). For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare. The CDI specialists are one of the many professionals whose roles are to review clinical documentations and provide feedbacks to healthcare providers such as the Physicians. The feedbacks are intended to fill the gaps in the documentation that addresses issues with quality measures, coding and the general care of the patients. The need for achieving a successful clinical documentation is driving many healthcare organizations to adopt a CDI initiative toward the goal of improving patients’ quality of care andShow MoreRelatedNurse Managers At All Levels Work Essay2142 Words   |  9 Pagesfrontline nurses while contributing to an organization’s success.† (Frankel, 2011) The nursing leaders are advocates who directly affect the quality of the nursing care along with also having a positive impact on healthcare through leadership. 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