What does clinical documentation improvement (CDI) focus on?

Clinical documentation improvement (CDI) primarily focuses on enhancing the quality of clinical documentation within health records. This improvement is crucial for accurately reflecting patient care, diagnoses, and treatment outcomes. High-quality documentation ensures that the information contained within medical records is complete, precise, and compliant with regulatory requirements. This leads to more accurate coding and billing processes, which can positively impact reimbursement rates and reduce the risk of claims denials.

By improving clinical documentation, healthcare providers can ensure that they meet the standards set forth by various regulatory bodies and align with best practices for patient care. Better documentation also supports improved clinical decision-making and outcomes, as it provides a clear and comprehensive view of a patient's medical history and current health status.

Although options that mention billing codes, training staff on coding, and reducing healthcare costs are relevant to the broader scope of healthcare operations and management, they do not represent the primary focus of CDI. Instead, these aspects are often outcomes of improved documentation rather than the primary goal itself. Thus, the emphasis on enhancing the quality of clinical documentation is critical in defining the purpose and objectives of CDI.