Clinical documents set the foundation for quality patient care. A comprehensive set of clinical documents tells you each patient’s medical history, disease progression, diagnoses, and any other information that guides their care. In long-term, post-acute care (LTPAC) and other settings where multiple specialists are treating a patient, accurate clinical documentation eases transitions between facilities and allows you and every member of a patient’s healthcare team to create a personalized treatment plan.
As a healthcare provider, you know that clinical documents are only as good as the data they include. Clinical documentation improvement (CDI) is a process aimed at getting you and other members of a patient’s care team the most accurate, quality information available to improve patient care and speed up the billing process. Bring clinical documentation improvement to your practice and improve your patient outcomes.
Accurate medical records are the key to personalized, effective patient care. CDI is the process of inspecting patient records to identify and fill gaps. A clinical documentation specialist will look at a patient’s record shortly after a visit to check for:
Accuracy
Completeness
Coding accuracy
Compliance
Severity of illness and complexity of treatment
In LTPAC, CDI improves a multidisciplinary team’s ability to collaborate. Each member of a patient’s healthcare team knows they’re accessing the most accurate, updated information to inform diagnostics and treatments.
These documents improve patient outcomes and also protect your facility by providing a thorough audit trail that meets regulatory requirements. Documentation issues in LTPAC health information exchange can delay patient care, frustrating clinicians and patients alike.
A recent study showed that CDI programs reduce readmission rates by 38%. Complete documentation also positively impacts your business.
On average, hospitals lose $5 million a year because of claim denials. Your LTPAC needs revenue to effectively treat patients. CDI processes lead to more complete medical record documentation and thorough patient records.
Your billing team can more effectively match codes to treatments and provide requested documentation to prove you've provided specific services. You see fewer claim denials and shrink the amount of time your accounts remain outstanding. More revenue helps you nail patient care through upgraded technology or expanding personnel, for example.
CDI also encourages your caregiving team to accurately note all patient conditions and treatments, which improves your chances of successfully submitting a claim. For instance, if you’re treating a patient with congestive heart failure with shock who also has kidney disease, a clinical documentation specialist can make sure your patient’s record is properly coded with the principal diagnosis and comorbidity so each treatment is properly attributed and your claim isn’t denied.
Clinical documentation improvement examples prominently feature EHR systems. In the LTPAC setting, clinicians use EHR software to record and transfer patient data, which helps them develop treatment plans or adjust treatments based on patient outcomes.
EHR is most effective when all providers are thoroughly recording data consistently. CDI specialists use software that integrates with your EHR to access and analyze patient data. They might assess an electronic health information export or look through the digital record on a compatible platform. CDI processes also assess EHR and make recommendations that can help improve documentation outcomes. Whether you need EHR system support for the CMS GUIDE model or for a private insurance payer, a CDI process gives you confidence in your data accuracy.
A CDI specialist may recommend standardized data entry processes or thorough training protocols so all your clinicians are capturing similar data and finishing their charting quickly.
Some CDI specialists use tools employing artificial intelligence, natural language processing, and machine learning to assess all your EHR records for inconsistencies or missing data.
AI helps CDI specialists analyze your charts. It can also help your caregivers keep better records. AI tools such as voice-to-text transcription, data analytics, and decision aids can make charting less of a chore.
AI can assess a patient’s medical records and match different services to their respective medical codes. It can also analyze a patient’s records and medical bills to identify missing or inaccurate data. This helps your medical billing and coding team submit clean claims the first time around, which reduces claim denials and boosts your revenue.
If you haven’t implemented a CDI process yet, start with a thorough audit. Work with a CDI specialist or an auditing platform to assess your clinical documents and note any discrepancies. An audit will show you trends that could mean your process has broken down.
For example, if your team members are copy-pasting information across patient records, you might see multiple inaccuracies, inconsistencies, or conflicting information. In this case, you would add a step to charting reminding your providers to carefully review any patient notes before submitting them.
It’s important to involve your clinicians in the CDI process. While talented, CDI specialists don’t always have the practical experience to understand everything that goes into clinical documentation. They might not know how condition severity and comorbidities impact diagnoses and care plans.
Clinicians work with CDI specialists to create documentation processes that capture the correct information without increasing the clinicians’ administrative workload. Involving clinicians in the process also enhances buy-in. Your clinicians get a broader view of how their documents impact other parts of your business, including patient satisfaction and revenue cycles. Instead of seeing CDI as another administrative task, they fully understand how it is improving patient care.
Clinical documentation improvement software can simplify your CDI process. ChartPath offers customized charting solutions to effectively implement your CDI process without burying your clinicians under more digital paperwork.
Our clients have reported 30% faster charting times without compromising accuracy. We offer tools and templates that speed up the process while making sure you’re capturing the right data consistently. You can do this across multiple facilities without logging into multiple systems.
Schedule a demo today and learn how we can help you.