Professionals in Clinical Documentation Improvement Programs

Clinical documentation improvement programs involve many people including documentation specialists, clinical research associates, documentation coordinators, drug specialists, medical coders, and IT auditors.

Nowadays, most hospitals and facilities have adopted clinical documentation improvement (CDI) programs to create clear and dependable medical documentation of their patients. The main purpose of this is to record all the medical data of a patient, including the details regarding the nature, severity, and extent of the medical problem; expected outcome of the identified problem; procedure of the medical care and treatment course; and the patient's reaction to the treatment program. It typically includes personal details such as age, address, sex, date of birth, history of vaccinations and other medical treatments, and family history of the patient.

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In other words, clinical-documentation provides a complete picture of medical and health history of a patient. It makes legal and insurance procedures easier and can be used for future reference. Hence, naturally, it becomes very important that it should be as precise and as complete as possible. The clinical documentation improvement programs are useful to improve the quality and accuracy of the medical data and help to reduce the diagnostic errors.

A clinical documentation improvement program usually incorporates many strategies, such as getting help from other health care departments, hiring, and training right professionals, ensuring accuracy of documentation, and preparing concurrent medical review. Recent innovations in the biotechnology fields have led to many improvements in the domain of this. It has now become a profitable industry in many parts of the world and offers jobs to thousands of people.

A clinical documentation program mainly consists of a clinical documentation specialist, who is responsible for the formation and preservation of all medical files. It is the duty of a specialist to assess and scrutinize the medical records and make sure that all the date and information are accurate and correct. He or she must possess fine communication skills and also be able to present the medical data in an interesting and readable style

It is imperative that a clinical documentation improvement specialist should have a clear understanding of the medical terminologies, medical classification systems, and various coding concepts. Mostly, the organizations employ a registered nurse as their improvement specialist. However, a specialist should also know how to work within the legal bounds and therefore should possess sufficient knowledge of relevant legal regulations.

As noted above, the clinical documentation improvement programs aim at documenting all information pertaining to the treatment of a patient, and hence need the services of many other people like coordinators, clinical research associates, documentation specialists, drug specialists, medical coders and IT auditors. All these professionals are supposed to work together to facilitate the implementation of an accurate clinical documentation. Moreover, the professionals are obligated to follow the ethical standards formulated by the American Health Information Management Association (AHIMA).

Professionals in Clinical Documentation Improvement Programs

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