HIMS 655 – Clinical Documentation Improvement (CDI)

Week Nine: Clinical Documentation Improvement (CDI)

Scenario: You have been asked to lead a Clinical Documentation Improvement (CDI) initiative in a fully paper health record dependent 30-bed facility. Although the purchase and implementation of an EHR are not feasible at this time due to the accompanying price tag and other impacting factors, the hospital administrator recognizes that while the EHR is currently out of reach, developing a CDI program is the first step in the right direction. Revisit your Week 3 “Health Record Documentation Policy” (paper-based record policy only) and Week 4 “Data Quality Beyond Borders: Modernizing Health Information Infrastructure Using AHIMA’s Data Quality Model” assignments that have been critiqued by your Professor. Using both materials from weeks three and four, devise a five (5) to seven (7) page briefing for the Chief of Staff, also known as the Chief Medical Officer, that outlines the below-listed topics. Submit it as a Microsoft Word document.

Deliverables:

1. Overview/description of the Clinical Documentation Improvement (CDI)
2. The benefits of implementing a CDI program
3. Consequences of not implementing CDI
4. List and briefly discuss at least six elements of a sound health record from the CDI perspective with emphasis on quality documentation practices
5. The significant role of physicians as it relates to timely, accurate, complete and legible health record documentation practices and timely response to physician queries within 48-72 hours. Outline the process of the department’s physician query process.
6. How the HIM department will lead the initiative. How the HIM staff can/will assist the Chief of Staff and the entire pool of practicing physicians?
7. Include an attachment of your policy and checklist (from weeks three (3) and four (4)) with a brief explanation as an interpretation of both (not counted towards the five to seven-page requirement; attach as an appendix)
8. Finally, devise a one-page six (6) month timeline that outlines the planning, designing and implementation of your proposed CDI program (not counted towards the five to seven-page requirement; attache as an appendix)