Policy on clinical documentation improvement

As with other organizational policies and procedures, policies on clinical documentation improvement (CDI) will improve communication and promote a successful, organized process. Clinical documentation Improvement has the goal of complete and accurate health record documentation that reflects the actual care and treatment provided during a healthcare visit, appointment or stay, and it is commonly executed via queries to the physician/provider that seek clarification or expansion on documentation that has been recorded in the medical record by that physician/provider. After the documentation is then concluded via the CDI query process, the patient record is forwarded to coding so that coding is completed after documentation is finalized in the CDI process.

To prepare the CDI policy, locate policies, procedures and guidelines provided for benchmarking in Module 01 under Benchmarking Resources. Alternatively, you may research policies, guidelines and standards on CDI on your own to use as a benchmark. Then create a facility policy on Clinical Documentation Improvement. Include at minimum:

  1. CDI initiative requirements (the goal of the program)
  2. Describe the qualifications of a professional CDI specialist
  3. Process steps for CDI
  4. Communication process between physician/provider and CDI specialist
  5. Identify the types of accounts included in the CDI process
  6. CDI query form, on a separate page from the policy.

The completed CDI policy should be 1 page. Create your own policy, do not copy from a resource and clearly identify all resources used for the policy creation.

Benchmarking against other organizations polices and/or available guidelines is an important step in the process of developing or revising polices and guidelines for a healthcare organization. Below is a list of benchmarking resources links to policies and guidelines and standards which relate to the topics you will be preparing policies for during the course project. You may select from the list for sources you would use to benchmark in each module and cite those that you use as a reference at the end of your policy or you may research policies, guidelines and standards on your own to use as a benchmark.

Banner Health “Documentation Requirements for the Medical Record-Policy and Procedure

Pennsylvania Hospital & Surgery Center Administrative Policy Manual – Medical Record Documentation Practices

Kansas County Health Department- Medical Records Policy

Joint Commission – “Do Not Use” List

UTMB Policy Manual

UTMB Health Procedure – Prohibited Abbreviations

UTMB Handbook of Operating Procedures-Policy Patient Right and Responsibilities

Creighton Health Sciences School Policy_ Patient Rights and Responsibilities

TennDent Policy HIPAA Access Control

University of Tennessee Health Science Center: Access to Protected Health Information

Illinois Administrative Code Joint Committee on Administrative Rules Part 250 Hospital Licensing Requirements

HCA Policy – Query Documentation for Clinical Documentation Improvement (CDI) & Coding – Compliance Requirements

UCSD Health Sciences Compliance/Privacy Program “Comparison of HIPAA’s 18 Protected Health Information (PHI) vs. Limited Data Set (LDS)

University of California – Legal Medical Record Standards Policy

Federal Register – Security and Electronic Signature Standards

Federal Register- Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Order; Securing Medications; and Post anesthesia Evaluations

AHIMA Online Research Journal Perspectives in HIM: “Storage Media Profiles and Health Record Retention Practice Patterns in Acute Care Hospitals”, by Laurie A. Rinehart-Thompson

AHIMA Practice Briefs and Papers Electronic Signature, Attestation, and Authorship

Clinical Documentation Toolkit (AHIMA Body of Knowledge)

An additional source to perform you own external review of policies, procedures, guidelines and standards is through:

Textbook: Health Information Management Concept, Principles and Practice – Appendix D Web Resource

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