Study: Examining the Clinical Documentation Improvement Landscape

When hiring professionals for clinical documentation improvement (CDI) programs, managers seek candidates with a background in both clinical and health information management (HIM) knowledge—challenging a common perception that a clinical background alone is sufficient, according to a recent survey by the American Health Information Management Association (AHIMA).

Respondents also said that while registered nurse and certified coding specialist are the most frequently required credentials, one of the highest preferred is AHIMA’s certified documentation improvement practitioner (CDIP) credential, indicating a growing understanding of the value and need for a higher level of educational certification, according to the research.

The article, “The State of CDI,” in the April issue of the Journal of AHIMA, analyzes key takeaways from the AHIMA survey conducted by the AHIMA Clinical Documentation Improvement Practice Council and performed to identify the current landscape and practices in the CDI industry.

The survey examined the type of organizations where CDI employees work, the departments under which teams are managed, professional backgrounds and the common credentials of CDI professionals.

Results found that most CDI programs fall under the HIM department. More than half of survey respondents also stated they hire HIM and certified coding professionals for positions in their CDI programs.

“The advancement of CDI programs and practices is essential to the delivery of quality patient care,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “The survey results show that not only do managers in these programs understand CDI professionals must have both a coding and clinical background, but that it’s becoming increasingly important for these professionals to have advanced credentials. With their knowledge and experience, HIM professionals are well positioned to lead the CDI path forward.”

The survey also examined the type of health records reviewed by CDI programs, with inpatient records accounting for the majority. The second-highest was a combination of inpatient, outpatient and professional records reaffirming that the industry is beginning to shift toward CDI reviews of outpatient health records. Full survey results are available to members here.

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