Clinical documentation improvement program

Clinical documentation improvement program

Frequently asked questions

Yes. This is an online program that can begin at any time.

Now more than ever, a strong, highly respected clinical documentation improvement program can make a difference in achieving the goals of improving quality care, improving case mix, and appropriate utilization of resources through quality information. In response to industry demand, 3M, in partnership with CHIMA, developed the program to lead to advanced certification in CDI.

Please send an inquiry to [email protected].

This program is for HIM professionals, nurses, physicians, and regulated health professionals who have a strong foundation in anatomy, physiology, pathophysiology, and pharmacology. These individuals are able to read and analyze all the information in a medical record and identify any gaps. As the goal of CDI is to improve the accuracy and completeness of clinical documentation, these groupings of individuals are best equipped to assess the clinical evidence and carryout the necessary follow up, including querying and educating physicians.

Physician documentation is often received in clinical terminology, not always listing the diagnostic
equivalent. Highly-skilled nurses have the in-depth knowledge of disease processes, symptomology and
appropriate treatment, as they have a background in the body systems, differential diagnoses, and
corresponding common co-morbidities/complications associated with various diagnoses.

Many organizations have transitioned nurses in their respective organizations into this role as they have
the knowledge and skills to “connect the dots” of signs and symptoms to lab/test results and then the
treatment, thus identifying opportunities for diagnosis and/or specificity what was not documented by
the physician.

The nurse continues to be a part of their respective unions as the position is just simply a transition to a
new role, perhaps within their own organization. Often these positions provide an opportunity for
nursing staff who have had injuries and who are unable to work at the bedside any longer.
The roles of a CDI specialist include directing and managing the daily operations and processes of the
program, such as:

 Conduct in-depth chart analysis to review the quality of the clinical documentation and
identify any gaps and opportunities for improvement.
 Act as a liaison between the coding team and physicians.
 Gather data and analyze performance metrics to focus CDI efforts.
 Develop tools, and resources to support both coding staff and clinicians.
 Provide training materials and deliver educational sessions.
 Implement solutions to leverage technology and electronic health record.
The position brings an exciting opportunity for nurses to bring their skill and expertise to the forefront
and be a part of improving overall healthcare in Canada!!!