Certified Clinical Documentation Improvement Specialist

Certified Clinical Documentation Improvement Specialist

Frequently asked questions

 CDI is about performing reviews of health records for conflicting, incomplete, and/or nonspecific provider documentation related to diagnosis(es) and intervention(s). The overall purposes of a CDI program are multifaceted and relate to all areas that the chart supports, including: 

  •  Legal 
  • Clinical 
  • Continuity of care 
  • Research 
  • Education 
  • Utilization: resource use, basis for funding, workload, case volumes, planning, and research and education

The clinical documentation improvement designation is for health care professionals who have a strong clinical background and are passionate about capturing the full picture of the patient care experience. Nurses and HIM professionals currently working in clinical documentation improvement roles, or those interested in these roles, would benefit from obtaining this designation and be recognized by potential and current employers as skilled and knowledgeable professionals in the clinical documentation improvement field. 

Clinical documentation improvement roles have increased in significance as many organizations have realized that health data is every bit as important as financial data. The importance of relevant and accurate data in health care reflects the increased importance of clinical documentation improvement roles. Various CDI roles may be available within health care facilities, vendors, and educational facilities that offer a CDI program, including clinical nursing specialist and clinical documentation improvement specialist.

For a more complete list of clinical documentation improvement roles, please visit the career matrix tool.

Certified clinical documentation improvement specialists may be employed by educational facilities teaching CDI, ministries/agencies/departments of health, hospitals, vendors in the CDI space, and more.