The 3M™ Clinical Documentation and Improvement Education and Training is a 12-module course that equips dedicated hospital staff that perform clinical documentation improvement (CDI) activities, such as chart review and querying, with extensive knowledge and resources. The content of this training is fully aligned with the Canada Coding Standards.
The 12-module course dives into an overview of clinical documentation improvement (CDI) challenges and considerations. The course provides a clinical review of common diseases/disorders, associated signs and symptoms, required physician documentation, potential query opportunities, and common required coding standards. Module Overview Module 1 - Describes what CDI is, the importance and the challenges, medical record review and requirements, stages of CDI, and the role of a CDI specialist Module 2 - Focuses on coding, classification, coding standards, and common guidelines Module 3 – Diseases and Disorders of the Respiratory System Module 4 – Diseases and Disorders of the Circulatory System Module 5 – Diseases and Disorders of the Nervous System Module 6 – Diseases and Disorders of the Digestive System Module 7 – Diseases and Disorders of the Hepatobiliary System Module 8 – Diseases and Disorders of the Endocrine System Module 9 – Diseases and Disorders of the Renal System Module 10 – Infectious diseases Module 11 – Diseases and Disorders of the Musculoskeletal System Module 12 – Focuses on factors affecting or affected by code assignment, how to select charts for review, reviewing a chart, the query process, and how to analyze the data For organizations that wish to increase clinical document improvement (CDI) awareness with physicians, nurse practitioners, and allied health staff, available education sessions help outline their role in making the program a success. Customized education for various departments is available in-person and as online video education, where the importance of a CDI program and physician involvement requirements are reviewed, highlighting medical case examples The 3M Health Information Systems Division also has a CDI web-based searchable tool which outlines documentation and coding requirements for common diagnoses. This tool is available to all health care professionals, including CDI specialists assisting with chart review, use as a reference during the coding process and for physicians when documenting. Our query and reporting software contains more than 75 customized query templates. For those who have appointed staff to perform CDI activities or for HIM professionals who wish to query physicians directly, 3M provides a custom software querying/reporting tool that tracks query requests, responses and provides a means to measure the impact on CMG post change in documentation. The CDI query software allows the CDI specialist to access the coded material of a chart, provides areas to document clinical indicators during a chart review that may indicate a possible query requirement, access code finder, send queries and track the queries sent, query response or lack thereof and the outcome metrics of the chart reviews.