The American Health Information Management Association has released a revised approach for improving clinical documentation, intended to bridge the gap between clinicians using electronic records systems and coding professionals.

The updated Clinical Document Improvement Toolkit for health information management professionals contains updated topics, and appendices that improve CDI program implementation and hiring. The toolkit offers guidance on developing and maintaining a structured program, and it contains recent changes in documentation requirements and ways to measure success in a clinical documentation improvement program.

Documentation improvement is intended to facilitate the process of getting records into a coded format, which is essential for achieving appropriate reimbursement and taking advantage of related IT systems.

Some of the revised topics include changes in documentation requirements and approval procedures; metrics for analyzing data to determine the success of the program and the role and benefits of the physician advisor in CDI; how to hire the right individuals to start a CDI program; and revised information regarding the use of secondary coded data and how it affects quality measures and third party audits.

The new appendices offer sample job descriptions, a checklist for CDI orientation training, a sample 90-day evaluation form, key monthly metric reports and graphs, and query or clarification monitoring samples.

These and other updates reflect changes in documentation requirements and CDI program success metrics, says AHIMA, which represents more than 103,000 health information professionals.

“Clinical documentation improvement programs are the center of healthcare today, as they serve as a crucial map to guide accurate, timely and consistent information,” said AHIMA CEO Lynne Thomas Gordon. “The transition to ICD-10 has intensified the need for this high-quality clinical documentation, but such results cannot be achieved without a structured program. With this toolkit, AHIMA provides the necessary tools and documents needed for ensuring a robust CDI program.”

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Caroline Spiezio

Caroline Spiezio

Caroline Spiezio is an intern at Employee Benefit News and Employee Benefit Adviser and a rising senior studying journalism and economics at Northwestern University.