Clinical Documentation Improvement - Principles and Practice

Clinical documentation is the foundation of every patient health record. This book clearly defines the term, explains its importance, and presents an objective and uniform set of principles that can be applied reliably in any healthcare organization’s clinical documentation improvement (CDI) program. The author identifies the key users of clinical documentation—from patients to clinicians to coding professionals to reimbursement entities—and throughout the book addresses how a strong CDI program affects them all.


Part 1 addresses the fundamentals of clinical documentation—assessing the current quality of the organization’s documentation and making the decision to implement a new program or improve the current one. Part 2 describes clinical documentation program implementation—from staffing and training through querying physicians, analyzing program data, and ensuring program compliance. Finally, Part 3 recommends and explains a process for growing and refining a clinical documentation program.

Key features:
• Expands on how the transition to ICD-10 will have an impact on the CDI process, highlighting specific coding scenarios
• Includes a new chapter on critical thinking for physicians, nurses, clinical documentation specialists, and coders
• Offers extensive guidance on CDI program analytics and their importance to a sustainable program
• New material including the latest on CDI technology solutions, an example query set, and work plans for CDI program implementation, APR-DRG CDI program, and denials management
• Additional guidance on CDI for APR-DRG and quality scoring
• Online appendices including an example presentation on physician education and engagement and strategy



About the Author

Pamela Carroll Hess MA, RHIA, CCS, CDIP, CPC is a health information management (HIM) professional with more than 30 years of healthcare experience in revenue cycle operations, electronic health record (EHR) applications, reimbursement, coding, billing, compliance, quality control, clinical documentation, and coding training. Ms. Hess has served in administrative, interim management, and consulting capacities within large academic and urban community hospitals. Her experience in the healthcare industry has focused on improving operational and financial performance in a variety of healthcare settings. Ms. Hess is employed as a Regional HIM Director for himagine solutions inc, the largest privately held HIM services organization in the country, where she manages himagine services. She has extensive experience as an HIM director in for-profit and non-profit facilities.