Clinical documentation integrity (CDI) initiatives validate that the clinical documentation within the health record has reached the highest level of integrity and specificity that is supported by the clinical evidence. This process is vital to the healthcare industry, CDI professionals ensure that clinical documentation accurately tells the patient’s story. To do so, they review the health record for any potential gaps in the clinical information. When a potential gap arises, the CDI professional will work with the provider to determine if further information can be documented to provide greater clarity.

There is an art to the CDI process.  CDI professionals combine both the clinical and coding perspectives when reviewing health record documentation. Both of these perspectives are vital to the accurate capture of information. If the clinical information cannot be accurately classified into a diagnosis and procedural coding system, the patient’s clinical picture could be skewed, and conclusions drawn from any later data analysis will likewise be incorrect.  There are also compliant standards that should be followed when clarifying documentation, these can vary by country.  However, two underlying principles are generally the same in all locations. First, CDI professionals work with providers to help them understand how to deliver high-quality clinical documentation.  Secondly, they should never tell the provider what they should document.

It is important for organizations to ensure they have CDI experts on their team. Expertise can be measured in many ways including assessments, skills checks, quality audits, and credentialing expectations. AHIMA has found that credentialing is a particularly effective way to measure the expertise on their CDI teams. AHIMA  supports this need through their Certified Documentation Improvement Practitioner (CDIP) credential. Those that pass this rigorous exam are recognized as experts in the field.

Documentation requirements for accurate diagnosis and procedural classification are continually changing, thus, requiring ongoing professional development. The search for qualified CDI trainers can be a challenge for organizations, which is why AHIMA started the AHIMA-Approved CDI Trainer program. The CDIP credential is a prerequisite to become an AHIMA-Approved CDI Trainer. This guarantees only CDI professionals who have advanced expertise in CDI topics area allowed to become AHIMA-Approved CDI Trainers.

In summary, CDI is an industry that requires professionals well versed in coding classification systems, clinical knowledge, and the ability to critically think through the documentation standards. As organizations develop CDI programs, they will need to hire experts well versed in the art of CDI. One avenue to recognize this level expertise is by requiring a respected credential, such as the AHIMA CDIP and develop a training process to keep abreast with the industry needs. When CDI departments are staffed with advanced trained CDI experts, the organization is setting themselves up for success.

Tammy Combs RN, MSN, CDIP, CCS, CNE 
Practice Director CDI and Clinical Foundations & Accredited Provide Program Director, AHIMA