Clinical Documentation Improvement

Clinical Documentation Improvement

Clinical Documentation Improvement


You have been asked to lead a Clinical Documentation Improvement (CDI) initiative. This small rural hospital is a 30-bed, fully paper-health dependent facility. Although the purchase and implementation of an EHR is not feasible at this time due to the accompanying price tag and other impacting factors, the hospital administrator recognizes although the EHR is currently out of reach, the importance of developing a CDI program is ultimately, a step in the right direction. Revisit your Week 3 “Health Record Documentation Policy” (paper-based record policy only) and Week 4 “Data Quality Beyond Borders: Modernizing Health Information Infrastructure Using AHIMA’s Data Quality Model” assignments that has been critiqued by your Professor. Using both materials from weeks three and four, devise a five (5) to seven (7) page briefing to the Chief of Staff also known as the Chief Medical Officer which outlines the following listed below.


  1. Overview/description of the Clinical Documentation Improvement (CDI)
  2. The benefits of implementing a CDI program
  3. Consequences of not implementing such a program
  4. List and briefly discuss at least six elements of a sound health record; from the perspective of a CDI program emphasis on quality documentation practices
  5. The significant role of physicians as it relates to timely, accurate, complete and legible health record documentation practices and the timely response to physician queries within 48-72 hours upon receipt. Outline the process of the department’s physician query process
  6. How the HIM department will lead the initiative. How the HIM staff can/will assist the Chief of Staff and the entire pool of practicing physicians
  7. Include an attachment of your policy and checklist (from weeks three (3) and four (4)) with a brief explanation as an interpretation of both (not counted towards the five (5) to seven (7) page requirement; list as an appendix)
  8. Finally, devise a 1-page six (6) month timeline which outlines the planning, designing and implementation of your proposed CDI program (not counted towards the five (5) to seven (7) page requirement; list as an appendix)


You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.