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Clinical documentation improvement

Capture what matters in the medical record.

Contact an expert
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Clinical documentation improvement (CDI) facilitates an accurate representation of the care provided through complete and concise reporting of diagnoses, comorbidities and procedures to ensure the acuity and complexity of the patient’s care is available to be coded.

It is crucial that hospitals accurately reflect the level of patient acuity in the medical record to ensure proper data, resource use, and appropriate funding.


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What you need to know about clinical documentation improvement

  • A surgeon looking at a tablet.

    High-quality documentation = high-quality data

    Often the challenge for the coder is to convert the clinical terminology into diagnostic terms, assess significance and assign the appropriate diagnosis codes.

    3M has found that medical documentation in over 50% of charts is not clear, specific or accurate, often due to missing or incomplete information.*

  • Two healthcare professionals examining a tablet with a computer monitor in the background.

    Documentation in the chart and the corresponding coded data is used for patient quality and outcome metrics

    Data is used to determine the ELOS, the hospital’s mortality rate, infection rate, and other quality indicators, all of which are publicly reported or benchmarked against other hospitals for comparisons. Comprehensive documentation is required to ensure that the data is a true reflection of hospital performance.

  • A hospital room with several doctors, and patient beds.

    Accurate data leads to appropriate funding for the acuity of service provided and resource consumption

    Physician documentation drives case mix groups and clinical codes that determine funding allocation for the hospital. Therefore reflection of the true acuity of the patient will ensure appropriate compensation for the care provided.

  • A CDI specialist writing in a binder and examining a computer monitor.

    Successful CDI programs appoint a CDI specialist

    CDI specialists conduct in-depth chart reviews and work with physicians to ensure the documentation fully reflects the patient’s episode of care. 3M are experts in training CDI specialists so they make an immediate impact in their role. The return on the investment for this high-quality training has proven to exceed customer expectations.*

    Contact an expert about CDI training

  • An icon of a patient with an IV stand.
    Patient records
  • An icon of a clipboard and magnifying glass.
    Clinical coding
  • An icon of a clipboard and a cross.
    Hospital data
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    Reporting
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    Funding

* Data available on internal file.


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Recent chart audits and studies done by 3M Canada Health Information Systems staff in Ontario show that more than 50% of medical records could be improved with more complete and accurate documentation.

These gaps are important opportunities for physicians and/or coders to improve data capture and documentation, leading to improved quality metrics and potential funding.

Findings
education
>50%
<25%
>25%
  • An icon of a doctor wearing a stethoscope.

    More than 50% of cases had opportunities for coder and/or physician education to improve data capture or documentation, impacting quality metrics and data.

  • An icon of a dollar sign and bar graph on a screen.

    More than 25% of cases resulted in an increase in weighted cases and affected potential funding.

  • An icon of a hospital.

    Fewer than 25% of the cases revealed no opportunities for improvement.

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  • An icon of a hand catching coins.

    A minimal number of clinicians are aware of the link between clinical documentation and accurate funding.

  • An icon of a laptop screen with a question mark on it.

    Lack of understanding was the #2 reason for clinicians not replying to the coding department.

  • An icon of a graduation cap.

    No medical courses at a tertiary level have formal training on clinical documentation.

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Data available on internal file.


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  • The logo for the CDI Clinical Documentaiton Improvement Specialist Certificate Program.

    Clinical Documentation Improvement Specialist Program

    3M and CHIMA have partnered to deliver an online Clinical Documentation Improvement Specialist Certificate Program. This program is open to experienced health care professionals wishing to become CDI specialists. Registration is available on the CHIMA website.

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