Clinical Documentation Improvement Program (CDIP)

New laws and regulations, ongoing federal reforms, and insurance initiatives are increasingly aligning quality outcomes with financial incentives and reimbursement. Medicare and many third-party insurers now consider patient severity of illness and post-admission complications when calculating payment. At the same time, accurate capture of patient acuity and risk of mortality impacts the hospital's case mix index (CMI), which influences quality outcomes and performance reports made available to consumers.

To ensure the clinical documentation contained in the medical record is as complete and thorough as possible, the Medical Center has initiated a Clinical Documentation Improvement Program.  The program consists of didactic sessions with all attendings, GME trainees, nurse practitioners, and physician assistants and provides concurrent feedback on documentation on the units.  Dedicated (CDS) clinical documentation specialists (RN) are responsible for working side by side with clinicians to ensure the medical record thoroughly depicts the patient's acuity.  The documentation specialists review the medical record on the unit and review for documentation clarity. If a question arises or a clarification is needed, the CDSs may leave a paper query form in the chart, e-mail the physician, or seek a face-to-face discussion to resolve ambiguity.

As clinical documentation improves, the hospital should achieve more accurate coding and better establish severity of illness, which in turn impacts a hospital's case mix index and ensures appropriate hospital/physician profiles.


Documentation Tips - General

Documentation Tips            Present on Admission
Other Medical Services             Principal Diagnosis

Documentation Tips - Per Specialty

Abnormal Lab Results Hypertensive Emergency
Acute Cardiac Ischemia Internal Medicine  
Acute Pulmonary Edema Malignancy
Acute Renal Failure Malnutrition
Acute Respiratory Insufficiency vs Failure Obstetrics
Acute vs Chronic Orthopaedics
Anemia Pathogenesis   
Bacteremia vs Sepsis Pathologic Fractures
Cardiology Peripheral Vascular Disease
Chronic Kidney Disease Staging Pulmonary Medicine
Chronic Respiratory Failure Sepsis
Closed Head Injury Shock
Diabetes Mellitus Skin Ulcers
DVT Stroke
GI Bleeding

Surgical Specialties

Heart Failure



Clinical Documentation Guide

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