Clinical documentation improvement spans the entire continuum of care from the time the patient presents to the Emergency Department or is direct admitted to the hospital until the time of patient discharge and the completion of the discharge summary. The CDI specialist’s role in enhancing the quality, completeness and effectiveness of clinical documentation is to recognize and treat the record as a communication tool as opposed to a reimbursement tool. Today’s present model of CDI incorporates and centers upon reimbursement as the primary outcome in the achievement of success of any CDI initiative. Unfortunately, the capability of the CDI profession to positively impact and capitalize upon the opportunity to assist the physician in accurately communicating and reflecting the actual care provided is not realized with this unrelenting focus upon reimbursement. Who really loses out is the patient who is totally dependent upon the physician and other ancillary care givers to accurately record and communicate the care rendered and response to clinical management and treatment from a continuity of care, quality and cost effectiveness perspective. Physicians are increasingly becoming tied to the concept of financial stewardship and the financial welfare of the patient, expected to consider the fiscal responsibility of the patient as a subset of care ordered and/or provided.
Focusing Upon Communication of Patient Care
Communication of patient care assumes a wide variety of meanings depen