The term 'Clinical Documentation Improvement' has been around for many years and described the early work of the reasoning behind the program's start. The early implementation of CDI programs were sold to CFOs (Chief Financial Officers) as a way to [...]

I was reading an article today about healthcare reform and the affordable care act, which linked an increase in CDI staff with the increased use of electronic health records. I began to reflect on the past 10+ years in the Clinical Documentation [...]

Electronic health records continue to be instituted within hospitals in order to more efficiently capture the documentation of the patient story. In a recent article “Clinical Documentation in the 21st Century” we hear the position of the ACP (American [...]

CMS (Center for Medicare & Medicaid Services) has been working to decrease a number of conditions they feel should not happen while patients are in the hospital = HAC (Hospital Acquired Condition). The ACA (Affordable Care Act) created the HAC Reduction [...]