What is clinical documentation integrity?
To stop the rise in errors, CDI was set as the standard maintained for clinical documentation that warrants the security, accuracy and comprehensiveness of a patient’s medical care documents.
This document contains the exact scope of both the patient’s diagnosis and services rendered by the provider.
A CDI specialist takes care of –
- existent and developing symptoms and examinations
- Review of diagnoses, continual medications, tests,
- Procedures of treatments and payer bill records
So, if safety is not ensured here, one falls trap to the Golden Rule for physician documentation; “If you didn’t write it, it did not happen.”
Why is clinical documentation integrity so highly talked about in healthcare?
WHO reports that over 50% of clinical documentation errors stem from administrative errors; patient record errors, prescription errors, and patient identification errors.
What makes matters worse:-
- This number only defines reported errors, with the actual number being much higher beyond our awareness.
- They are all preventable medical errors which occur with alarming frequency in US hospitals.
Clinical Documentation Integrity and Healthcare Decision-Making
The difference between a clinical documentation integrity job and a clinical documentation improvement job lies in the direct relationship between one with the other:-
Maintaining clinical data integrity → Improving clinical documentation
Beyond patient safety, CDI affects-
- Payer billing and reimbursement,
- Legality surrounding compliance and security,
- Maintenance of staff workflow and decision-making
- Physician report cards and revenue
Digitisation in Clinical Documentation Improvement
Healthcare stakeholders consider the top 3 factors for efficient healthcare administration –
- Patient safety
- Legal compliance
- Hospital revenue
The advantages of maintaining clinical data integrity are enhanced with the implementation of AI in healthcare. An effective CDI program invests in cutting-edge integrity software to achieve these three factors more efficiently.
100% Clinical Documentation Integrity With RevMaxx
RevMaxx’s AI Medical Scribe upholds the same principles behind CDI. Our team of varied medical backgrounds collaborate with technological expertise to build a solution that takes over the burden of clinical documentation from physician’s hands.
RevMaxx becomes a physician’s best CDI practice tool by:
- enhancing accuracy with sophisticated Machine Learning algorithms,
- reducing manpower and training costs with ambience technology,
- minimizing physician burnout and overload by taking over documentation protocols,
- increasing patient satisfaction and physician revenue by HIPAA-compliant codes and records.
RevMaxx believes in hybrid work ethics: the interface between CDI specialists and accurate AI medical coding, to create holistic solutions for our doctors and their patients.
Who is a Clinical Documentation Integrity Specialist?
Working behind upholding the integrity of patient records, CDI specialists “bridge the gap between provider documentation and healthcare code assignment.”
Their job description entails:
- Determining the accuracy and completeness of clinical documentation.
- Ensuring complete HIPAA compliance on the security of medical records
- Reviewing the suitability and appropriateness of medical codes by cross-checking extensively.
- Collaboration with doctors and provider teams to facilitate an overall efficient review process
Clinical Documentation Integrity Specialist Job And Employment
A CDI Specialist’s handling of data is even more in demand at hospitals with the technological data overload produced in healthcare every day.
A RootsAnalysis report shows the estimated data generated in a standard hospital is 50+ petabytes of patient data and operational data per day. That’s over 1030 Terabytes!
Furthermore, the amount of data generated by the healthcare industry is anticipated to grow exponentially, with a CAGR of more than 35% until 2025.
However, this data is not accessible or digestible for both patients and clinicians. Why?
There is a huge patient overflow.
With the rising population, adults over 65 visit doctors 20% more frequently than before, with doctors seeing a massive increase in hospitalization rates today.
To handle this patient overflow, hospitals hire CDI specialists, freeing the hands of a physician 4x more, and giving them back time for actual clinical care with patients. The benefits of a CDI specialist come three-fold:
- Hospitals – in healthcare operations
- Physicians – increase in revenue, decrease burnout
- Patients – promote data security and safety
How to Become a CDI Specialist?
A Clinical Documentation Integrity Specialist must possess acute skills that adhere to the CDI program’s policies and physician query templates. The specialist should also utilize top-notch electronic CDI tools like RevMaxx to review and produce the highest quality clinical documentation.
The following prerequisites make one eligible for the most reputable, standard hospital settings:
- Qualification
CDI requirements range from as low as having a high school diploma. What is preferred by most hospitals are skilled professionals who will contribute to their setting. Hence, unlike a medical scribe qualification, more advanced qualifications follow how to become a CDI specialist. The following qualifications needed are:-
- High school diploma
- College degree: The highly competitive landscape demands a prior healthcare background; Bachelor’s in either nursing, health information management, or physiology/human anatomy
- Advanced training: more specialised fields in the department may require advanced degrees or certifications.
- Skills
- Clinical Experience and Knowledge: Understanding disease processes, diagnostic findings, and work experience in real-time with treatment protocols.
- Coding Proficiency: Familiarity with ICD-10-CM, MS-DRG, and other coding systems.
- Regulatory Compliance Skills: Knowledge of medical coding guidelines and healthcare compliance requirements.
- Computer skills: Proficiency in Microsoft Office, particularly Excel, Word, and PowerPoint.
- Communication skills: Handle collaboration through concurrent charting and interaction with physicians
- CDI Training and Certification
Unlike medical scribes whose certification is optional, aspiring CDI specialists must have a minimum certification or degree to be hired in a reputable healthcare setting.
This is because CDI specialists handle the most crucial aspect of clinical documentation: review and error detection. With prior experience and academic credentials, a CDI specialist can vouch for their qualification with their knowledge in medical coding and documentation.
For example, the CDIP examination needs candidates to not only hold an associate’s degree or higher, have a CCS, CCS-P, RHIT, or RHIA credential, but also have 2 or more years of CDI experience.
Best CDI Certifications
- CDIP certification organized by AHIMA
Focus: Provides industry-level training to make candidates ready to take on complex healthcare clinical documentation tasks
- CCDS and CCDS-O certifications, organized by ACDIS, which require two years of experience in CDI and passing a comprehensive exam.
Focus: Provides specialization training on both inpatient and outpatient CDI programs, known for their focus on extensive CDI practices.
- Clinical Documentation Integrity Certificate, organized by Charter Oak, accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).
Focus: knowledge of clinical documentation improvement (CDI) tasks, procedures, policies, philosophy, and value, with emphasis on filing reimbursements.
- IGMPI offers Clinical Documentation Improvement Certification.
Focus: Documentation assessment and improvement in medical coding, with a focus on practical case studies.
Best CDI Certification Online
- AHIMA CDIP Certification offers online courses and exam modules.
- ACDIS CCDS and CCDS-O Certification provide online certification programs like CCDS and CCDS-O, along with foundational training through the CDI Apprenticeship.
- AAPC Certified Documentation Expert Outpatient (CDEO) certification offers an online program and exam format for a virtual experience of the best training on clinical documentation.
Conclusion
Datafication of healthcare records has not only impacted the importance of clinical documentation integrity but also its use of advanced CDI software like Revmaxx to produce the best documentation. Current trends are ripe with the hybrid of AI and medical expertise, with Revmaxx showing up at the top of the line. Understanding physician requirements, RevMaxx’s seamless interface works best with aspiring CDI specialists across all specialities, thereby paving the way forward to promote hybridity in the workspace.
To know more about how RevMaxx helps doctors in achieving Clinical Documentation Integrity, click to request a demo here.
