CDI - Clinical Documentation Improvement Programs

This article mentions about the various clinical documentation improvement programs that have been set forth in regulatory compliance of the medical industry in UK where clinical audits are common.

In the United Kingdom, the NHS or the National Health systems have embarked on a journey of clinical governance. The regulatory body endeavors to bring forth a process of quality assurance in the care giving regimen followed in member institutions and hospitals. The idea is to standardize medical documents, paperwork, and care giving diagnostics and to develop a uniform code for medical paperwork that can be utilized by various stakeholders in the patient care process. The program focuses on clear, concise, comprehensive, correct, collaborative and complete clinical documentation which is also subject to periodic clinical audits.

CARE IMPROVEMENT

The clinical documentation improvement program is meant to cover the entire process of patient admission, diagnostics, laboratory procedures as well as medicine and equipment usage, identifiers, measurement and management. The whole idea of the program is to ensure that patient care is consistent and medical history and recall is not based on attendant's memory or medical files but at one central place from where it can be accessed by any doctor or medical practitioner.

The clinical governance program demands that documentation in professional care giving including physiotherapists, dieticians and other healthcare professionals is recorded well. The essence of the programs is to make clinicians more accountable and also to safeguard the patient by ensuring doctors and caregivers do not ignore minute information that could be significant in the medical history of the patient. The whole program is based on guiding principles and there is a Clinical Quality Assurance Program that monitors the implementation of these guiding principles in the documentation practices, tools and systems of organized medical institutions and even in case of other professional care givers.

The clinical audits conducted by the various auditors confirm compliance to the guiding principles as well as to standards of documentation, coding and architecture of the CDI or Clinical Documentation Improvement program. CDI includes vendors and other third party associates also who ensure that the documentation and record keeping is correct. All departments, functions and personnel of the hospital and clinic are advised to be abreast of the NHS guidelines as well as the CDI standards so that adherence, compliance and ongoing monitoring are guaranteed.

The CDI program includes the labs as well as emergency care departments. The administration of CDI is often done through CDI coordinators, documentation specialists, and auditors, coders and even Systems and IT auditors. CDI program has opened new career opportunities like the clinical auditors. Clinical Auditors conduct clinical audits of various functions. The technology advantage helps in the program implementation.

Various computerized tools and applications have since emerged in the UK that help the practitioners adhere and demonstrate compliance to the new NHS guidelines and Clinical Documentation Improvement program. The technology helps clinical audits by enabling database searches and standard code adherence. The clinical audits are the stepping stone to a full breadth corporate governance program that is based on seven governing pillars.

CDI - Clinical Documentation Improvement Programs

CARE IMPROVEMENT