What is the aim of clinical documentation improvement (CDI)?

The aim of clinical documentation improvement (CDI) is to enhance the accuracy and completeness of healthcare documentation to support coding. Accurate documentation is essential in ensuring that the medical record reflects the patient's condition and the services provided. This supports correct coding, which in turn is crucial for billing, reporting quality metrics, and ensuring compliance with regulations. CDI programs help healthcare organizations identify areas where documentation may be lacking or unclear, ultimately leading to better patient care, improved financial outcomes, and enhanced data integrity for reporting purposes.

While improving patient wait times or increasing satisfaction scores can be beneficial outcomes of an efficient healthcare system, they are not the primary focus of CDI initiatives. Additionally, although simplifying the coding process can be a result of better documentation, the core objective is to ensure that documentation accurately represents the care provided. Thus, enhancing documentation serves as the foundation for effective coding and reimbursement.