What is Clinical Documentatiton Improvement (CDI)?

An approach, often supported by specialized software, designed to help physicians improve their documentation of patient encounters and procedures. Implemented chiefly by hospitals, CDI programs aim to present a more accurate description of the care that has been delivered to patients. Better documentation can contribute to better continuity of care, because it helps subsequent caregivers understand a patient’s status and what has been done for him or her. In addition, it can boost a hospital’s bottom line by ensuring that the severity of a patient’s condition is properly documented to support the maximum allowable charges. And under the ICD-10 diagnostic coding system, which is much more complex than the previous coding system (see separate entry), complete documentation is essential to support insurance claims.

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