Clinical Documentation Improvement: Principles and Practice

ISBN: 9781584265023
ISBN-10: 1584265027
Copyright: 2015
Edition: 1st
Author: Hess, Pamela Carroll
Doody's Expert Review    Score: 85
Reviewer: Linda Hyde,  RHIA  (Hyde Consulting)
This book describes the basic principles behind, and the importance of, high-quality clinical documentation. It is designed to be applicable to any organization that maintains a patient health record and needs to create or enhance their clinical documentation improvement (CDI) program.
The purpose is to provide a comprehensive reference that identifies the need for and uses of consistent and reliable clinical documentation. It describes the uses and users of the clinical health record and the effect of quality documentation on patient care, reimbursement, and quality initiatives. The book provides a step by step process for creating a CDI program, through obtaining key support, to staffing and implementing the program. Best practices are also identified to assist in evaluating and maturing your CDI program over time.
This book is suitable for anyone who is involved in developing or maintaining a CDI system. It is also an appropriate book for educational programs that are introducing students to the need for and concepts behind CDI programs.
This book is divided into three parts that cover the fundamentals of clinical documentation, implementing a clinical documentation program and growing and refining the clinical documentation program. Each chapter ends with a conclusion paragraph, chapter quiz, and references. The appendix includes five case studies showcasing various real-world clinical documentation improvement programs across different healthcare settings. There are also instructor materials available upon request.
Designing and implementing clinical documentation improvement programs are critical components of managing health information for any healthcare organization. This book presents uniform principles for evaluating and improving clinical documentation as well as demonstrating the importance of CDI programs. It provides up-to-date information on the collaboration needed for insuring quality clinical documentation in today's EHR systems, the importance of data analytics, and use of CDI technology tools. It is a valuable resource for anyone who has a role or interest in CDI. This book updates and replaces Clinical Documentation Improvement: Achieving Excellence, Russo (American Health Information Management Association, 2010).
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