Introduction

Introduction to Clinical Documentation Improvement and Integrity (CDI)

We are pleased to welcome you to this specialized course, which aims to enhance the understanding and practices of Clinical Documentation Improvement/Integrity (CDI). CDI has become a cornerstone of modern, value-based healthcare.

Why is this course important?

Today's healthcare providers face unprecedented challenges. Data indicates that 60% of physician burnout is due to administrative burdens and excessive documentation, which negatively impacts direct patient care time, patient satisfaction, and the accuracy of clinical decision-making. This is where CDI emerges as a strategic solution.

What is CDI?

CDI is a systematic process to improve the quality and accuracy of clinical data collection to ensure that medical documentation:

• Accurately reflects the patient's complete health status.

• Supports precise medical coding (such as ICD-10-AM, ACHI).

• Leads to fair and appropriate revenue through accurate billing.

• Improves quality metrics and reduces legal and regulatory risks.

• Supports value-based care and quality research.

Course Contents

• Fundamentals: The definition of CDI, the golden rules of documentation, and its importance in the revenue cycle management (RCM) and healthcare.

• Historical Evolution: Tracing the evolution of CDI from the DRG system in the 1980s to the current era of artificial intelligence and advanced analytics.

• CDI Goals and Challenges: Understanding the goals of a CDI program and common obstacles, such as physician resistance, lack of awareness, and time constraints, and how to overcome them.

• Roles and Responsibilities: Defining the roles of the CDI specialist and the medical team (practitioners, nurses, coders) in achieving documentation integrity.

• Physician Queries: Understanding the correct and compliant querying process for clarification without "leading" to accurate documentation.

• Quality Standards: Connecting CDI to key Saudi healthcare standards (such as NPHIES) and medical record standards (such as completing the medical summary at discharge).

• Financial and Quality Impact: How accurate documentation leads to precise coding, which enhances the accuracy of the RCM cycle and enables sound business decision-making.

Expected Outcomes:

By the end of this course, participants will be able to:

• Understand the vital link between accurate clinical documentation, quality, and finance.

• Identify deficiencies and ambiguities in medical records.

• Apply CDI principles and tools to improve care quality and financial outcomes.

• Effectively interact with CDI teams and understand the querying process.

Course Approach:

The course relies on practical, real-world examples (case studies), interactive discussions, and analysis of common documentation scenarios to understand the applications of CDI within the Saudi healthcare environment, which is undergoing rapid transformation towards technology adoption and national exchange standards (NPHIES).

We wish you a beneficial and fruitful learning experience.

Description

Learning Outcomes:

·        Understanding the definition and importance of clinical documentation improvement.

·        Understanding the goals of clinical documentation improvement.

·        Knowing the golden rules for clinical documentation and coding.

·        Being aware of and knowing how to use documentation tips.

·        Familiarizing yourself with documentation and coding issues.

·        Understanding the concept of the medical record.

·        Understanding the criteria for proper documentation in the medical record and how to write it correctly.

·        Understanding the definition of CDI and the main outlines.

·        The implementation in Saudi Arabia.

Course Content

Introduction to Clinical Documentation Integrity

Introduction to Clinical Documentation Integrity

Health care Reform in KSA

The "Golden Rule of Documentation

What is CDI The Evolution and History of CDI

CDI challenges

The Role and Objectives of the Clinical Documentation Integrity Specialist

Effect Of Accurate Documentation And Coding Due To Clinical Documentation

What is the A Query

RCM UNITS ) Revenue Cycle Management)

Pricing Unit/ CDI

"STANDARDS FOR CARE AND MEDICAL RECORDS"

Provision of Care Standards

Medical of Information Standards