Clinical Documentation Management Program

A truly beneficial clinical documentation improvement program must encompass so much more than just what it stands for on the surface. On the surface, it is just an audit program that makes changes required of a medical institution in order to improve and stay ahead of the latest procedural and technological trends. But what a documentation improvement program really is (in the right hands), is a carefully designed program made to meet the specific needs of individual hospitals and medical institutions across the country to make the changes they need not just generic adjustments.

A documentation improvement program is a peer-to-peer educational training tool that educates your medical staff and mid-level providers in new and creative ways. Some of what they will learn will be conducted in large seminars and but there will also be plenty of specifically targeted small group classes so as to be both broad and specific with all members of staff.

 CDI education programs touch on aspects of documentation that provide fullness and unprecedented value to a patient’s crucial medical record. Clinical documentation improvement programs should assist in working with your staff and your coders on the clinical side of the diseases and procedures filing, to help to ensure that there is full comprehension. A truly deeper understanding of the procedures for which they assign ICD-9-CM codes is necessary in order to have a staff that is operating to its full potential. That is what documentation improvement programs are all about: helping hospitals and other medical institutions to realize their potentials and maintain them at all costs.

CDIP (which stands for clinical documentation improvement program) is a way for medical institutions and their staff to gain a further understanding and foothold in the industry and to make the necessary adjustments and changes in the crucial areas of care. These areas include coding, reimbursement procedures and timing, rounding schedules, data organization, technology training and competency, patient satisfaction, payroll notices, discharge notices and trackers and of course, medical training.

A lifetime of high quality of care for patients begins with necessary adjustments and improvements on documentation and data collection. These much needed changes help to  form the basis of the medical record that a patient will carry with them for all of their days. The medical record is a giant map of a person’s ‘physical life’ meaning that it documents all the things that have physically happened to a person and stores this information so that it may be used to understand future illnesses that person may have and aid in future treatments.

Visit the clinical documentation improvement forum today to learn more.


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