CDI Basics: Clinical Documentation Improvement

Strong clinical documentation leads to better patient outcomes and timely reimbursement. It is the foundation of every medical record. Its purpose is to tell the patient’s story. When documentation is vague, ambiguous, or missing, there are gaps in the patient’s information that may be critical to optimal outcomes. But fear not–this CDI basics introduction course will help you outline best practices.

Historically, clinical documentation has been focused on the hospital records. Many hospitals employ clinical documentation specialists who concurrently review the records and query the provider for unclear evidence of the patient’s status. Today, the physician practice is included in clinical documentation quality as well. Prior to this shift, the physician practice protocol has generally been reactive rather than proactive. In order to meet timely reimbursement and shift to value-based payment methodologies, now is the time to improve documentation quality.

Healthcare is rapidly changing. Stay in the game by taking a proactive approach to clinical documentation!

In this CDI introductory course, we will review the following areas: 

  • What quality clinical documentation looks like
  • Documentation’s link to medical necessity
  • How to prevent problematic documentation
  • Logistics for managing improved documentation to avoid common pitfalls
  • An overview of concurrent reviews and physician queries

 

Course Format

This course is administered completely online through MMI’s password-protected learning site. The course is quick, convenient, and self-paced while still offering an exceptional learning experience including reading material and practice questions. You will receive the CEU certificate in PDF form upon completion of the final online exam.

  • Estimated Length: 3 Hours
  • Worth: 3 CEUs
  • Pre-Approval: This course meets AAPC guidelines for 3 CEU credits

Click here to view the entire continuing education course listing through MMI.

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