A clinical documentation improvement program was created to help improve medical documentation. This article will discuss how to implement this program and how it can benefit a medical facility.
The field of clinical documentation is still relatively new and there is a lot to be done. Due to the serious nature of the field, many regulations and rules are in place to guide how documentation should be done.
Some areas need to be updated on a regular basis in order to ensure the documentation is accurate and complete. Hospitals and other healthcare facilities have been required to use the medical documentation improvement program with clinical implementation experts due to the new regulations.
The main goal of the clinical documentation improvement program is to improve the documentation process so it can be more precise and complete. This will allow the documentation to accurately reflect the severity of the patient's illness.
By indicating how much the patient actually consumed the resources, the clinical documentation improvement program helps to improve documentation.
Clinical documentation improvement programs ensure that documentation is accurate and of higher quality. This will ensure that patients receive better treatment and documentation meets all regulations in each country. It has several stages that will allow it to accomplish the job it is meant to do.
The query stage is usually the first. Here, the CDI or clinical documentation improvement specialist will review the entire documentation and consult with the staff and attending physicians to find any flaws.
Specialists will investigate all possibilities to improve the documentation. The documentation may not always be complete because it lacks specific details and clarifications. These details will be included by the specialist. The specialist will then suggest ways to improve the documentation.