Clinical Documentation Improvement

This CDI program contains four (4) self-paced online courses directed toward clinical documentation specialists or related roles in healthcare settings. This is a useful program for coding professionals; however, the courses focus on documentation assessment and improvement as they support code assignment (the program does not contain any training on how to code for reporting or indexing).

The following general information applies to all four courses in this program:

Courses

CDI: Principals to Establish and Expand a Program

This six lesson course will review the processes used for organizations and providers to determine if a new CDI program is needed or if there is an opportunity to expand an existing CDI program. In addition to identifying the need for CDI, this course will review the tools that are used to create or expand a CDI program. With CDI programs expanding into numerous healthcare settings this course is essential to identifying the steps needed to set up successful CDI programs.

The first lesson of this course walks you through the steps of performing a gap analysis. Lesson two then evaluates the national guidelines and regulations for CDI. Lesson three defines the stages of development for a successful CDI program. Lesson four constructs a plan to hire the right staff for the CDI program’s success. Then lesson five assesses common CDI metrics and analyzes the data obtained from these metrics. Finally, lesson six illustrates the relationship between the International Classification of Diseases (ICD) and CDI. After completing this course, you will have the information needed to identify if your organization needs to implement a CDI program or expand an existing CDI program.

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Bulletproof Policies and Procedures Clinical Documentation Improvement (CDI) Programs

This six lesson course will review the process of developing effective policies and procedures for a CDI program. It is crucial to have policies and procedures in place to guide the CDI team. These are vital in providing direction and streamlining the workflow of CDI professionals. These documents can be challenging to develop; this course will break down this process into easy to follow steps for the policies and procedure that are most crucial to CDI programs.

The first lesson of the course discusses the elements of an overall CDI program policy. Lesson two then walks the learner through the components of a record review policy to provide structure to the review process. Lesson three explores the segments of a query policy to ensure the program is following a compliant query practice. Lesson four investigates the procedure of validating the classification assignment of both inpatient and outpatient prospective payment systems (PPS). It is important to identify a process to finalize any discrepancies through an escalation process; therefore, lesson five distinguishes the various steps of an escalation procedure. Finally, lesson six analyzes the components of a policy which supports the role of a physician advisor/champion. After completing this course, you will have the information needed to develop policies and procedures to support the ongoing operation and success of your CDI program.

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Recognizing the Value in Clinical Documentation Improvement (CDI) Metrics

This six lesson course will review the metrics used to recognize a CDI program’s successes and opportunities for improvement. In addition to identifying these metrics the course will break down these metrics into easy to understand calculations. Metrics will have a different meaning to different professional groups. Each lesson in this course will review metrics from these various perspectives and provide presenting tips for these differing professionals.

Lesson one critiques the reporting metrics that would be of value to a CDI program’s steering committee. Lesson two then selects reporting metrics that would have valuable meaning to provider leaders. Lesson three compiles reporting metrics of importance for the CDI team. Lesson four constructs reporting metrics of significance to the interdisciplinary team (IDT). Lesson five discovers the public healthcare data that is impacted by a CDI program. Finally, lesson six assesses the benefits of benchmarking an organization and/or provider against their peers. After completing this course you will have the information needed to interpret the numerous metrics available to a CDI program.

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Continuous Clinical Documentation Improvement (CDI) Advancement

This six lesson course will review the process of ongoing maintenance and continuous improvement of an established CDI program. Once success is achieved it is important to continually monitor the program to ensure ongoing advancement. This monitoring is vital to identifying both the successes and opportunities for a CDI program. When successes or opportunities are identified, action plans can be developed to continue a process or make needed procedural changes.

Lesson one critiques the variety of traits that support effective leadership. Lesson two evaluates ways to measure successful provider engagement and discuss the benefits that come with that engagement. Lesson three assesses the components of successful staff meetings. Lesson four appraises the value of intradisciplinary team meetings. Lesson five assesses ways to promote the CDI program. Finally, lesson six analyzes the importance of ongoing audits. After completing this course, you will have the information needed to maintain and provide ongoing improvement to your CDI program.

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