clinical documenation improvementIt’s the hot topic right now.  Everyone is talking about it. DOCUMENTATION! How do we prepare physicians for the new documentation requirements within ICD-10?  Is our clinical documentation improvement program prepared for the transition?  There are a few key steps that can be taken to avoid the iceberg of documentation when you’re looking too prepare and assess your clinical documentation improvement program.



Audit the CDI Program
The State of HIM Report recently released showed that 75% of CDI programs are audited.  An interesting statistic came up in the correlation between audited programs and their efficacy.  On a scale of 1 to 5 (5 being best) audited programs scored almost a full point higher than non-audited programs for efficacy.  Simply put, if documentation is a concern a clinical documentation improvement audit is a necessary first step.

Mind the Gaps
When assessing a clinical documentation improvement program, there are many others areas that need attention outside documentation.  Reporting structure, communication protocol, supporting technology, policy and procedures and numerous other areas can directly affect a CDI program’s success.  Finding gaps in these areas, while time consuming, is important.

Do Something About It
Assessment is worthless without action.  When a gap is found or an audit turns up an area needing attention you need to act.  Developing work plans to address gaps in a program helps keep everyone on the same page and pointed towards the same goal.  This includes assignment of specific tasks to various parties, regular tracking to completion of the plan and basic project management skill.

Take a look at the clinical documentation improvement iceberg by clicking the hyperlink in this sentence.  Sufficient documentation can be achieved.  Just remember to get below the surface.