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Overview

Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient’s disease burden and scope of services provided.

Successful clinical documentation integrity (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.

The convergence of clinical care, documentation, and coding processes is vital to appropriate reimbursement, accurate quality scores, and informed decision-making to support high-quality patient care. To that end, CDI has a direct impact on patient care by providing information to all members of the care team as well as those who may be treating the patient at a later date.

Training and Resources

AHIMA is committed to advancing CDI by providing education and training, certification (CDIP® credential), and other valuable resources to CDI professionals. Whether you are new to CDI, transitioning from a coding or clinical background, or an experienced CDI professional, AHIMA provides education and resources to support your lifelong learning and continued advancement.

 

18 lessons | 26 CEUs

Self-Paced Clinical Documentation Improvement (CDI) Inpatient-Outpatient Academy

The Self-Paced CDI Inpatient-Outpatient Academy is a comprehensive series of 18 lessons that cover the best practices of CDI. 

18 CEUs and CNEs

Coming in 2021: CDI Trainer

  • AHIMA’s advanced workshop prepares CDI professionals to train others in industry best practices.
  • Learn how to teach complex subjects to include health record reviews, compliant queries and important CDI metrics.

eBook | First Edition

Clinical Documentation Improvement: Principles and Practice

Learn the fundamentals of clinical documentation, how to implement a CDI program, and how to grow and refine an existing program. 

Hardcover | First Edition

Certified Documentation Improvement Practitioner (CDIP) Exam Preparation

This book is for experienced CDI professionals to test their knowledge regarding high-quality documentation and prepare to sit for AHIMA's CDIP exam.

Hardcover | First Edition

Clinical Documentation Improvement for Outpatient Care

This is an all-inclusive guide to establishing and enhancing CDI programs for the outpatient and professional fee setting. 

10 webinars | 30 min each | 0.5 CEUS each

Diving into Documentation Webinar Series

These 30-minute on-demand presentations focus on the hot topics impacting clinical documentation integrity and are presented by industry experts.  

21 webinars | 29 CEUs total

Clinical Documentation Integrity Insight Courses

This course  series  includes  21 webinars that provides  a comprehensive educational approach to CDI based on body systems and diagnostic categories. 

1 CEU

The Crucial Role of a CDIP in Revenue Cycle Management

Successful CDIPs should have a deep level of clinical knowledge in analyzing patient health records to provide assurance about the captured data from the physician and the coder to ensure accuracy in providing quality patient care.

Practice Briefs (Members only)

Learn best practices for topics such as denials prevention and management as well as the art and science of CDI. 

Toolkits (Members only)

Be prepared to handle any situation in the workplace with toolkits covering topics such as disaster planning, breach management, and telemedicine. 

AHIMA Query Template Library

A compliant query process is an essential element of a CDI program. AHIMA has developed a query template library that includes more than 140 templates covering documentation needs in both inpatient and outpatient settings. 

March 18, 2021

Documenting Acute Encephalopathy in COVID-19 Patients

Looking for the underlying condition causing the encephalopathy is beneficial because it can help in the identification of the principal diagnosis.

 

March 10, 2021

IFHIMA White Paper Fosters ICD-11 Planning, Adoption Around World

A white paper written by a group of global HIM professionals and published by IFHIMA discusses how early planning, coupled with HIM leadership, is critical for countries transitioning to ICD-11 in an increasingly digital and data-oriented world.

January 27, 2021

COVID-19 ICD-10-CM Coding Timeline for Outpatient Services

When COVID-19 emerged in early 2020, new ICD-10-CM codes to identify this condition were not available. Subsequent ICD-10-CM codes and guidelines for reporting COVID-19 changed many times as the pandemic evolved throughout 2020.

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