AHIMA: A Case Study

Clinical documentation improvement (CDI) is to ensure that clinical documents reflect the scope of services provided to a patient. Clinical documentation is the core to of every patient encounter. Health information management (HIM) professionals are recognizing the need for detailed clinical data for diagnostic and procedural coding, research, and patient safety. Facilities are improving clinical documentation by implementing programs. According to AHIMA (2015) these programs were developed to teach health care professionals what were not taught in medical schools concerning organization of healthcare records and completing documents in a timely manner. HIM professionals impact CDI programs by providing education regarding complaint documentation to physicians. The AHIMA has a CDI toolkit that focuses on the goals of clinical documentation, these goals include identifying and clarifying missing, conflicting, or non-specific physician documentation related to diagnoses and procedures, support accurate diagnostic and procedural coding, DRG assignment, severity of the …show more content…
AN acute care setting should have a trained professional skilled in coding, disease process, record content knowledge, great communication skills, and be able to review records for details needed for appropriate reimbursements (Sayles, 2014, pg. 121).
Improving the accuracy of clinical documentation can reduce compliance risk, minimize a healthcare facility’s vulnerability during audits, and provide insight to legal quality of care issues. Clinical documentation improvement has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date (AHIMA,