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Clinical Documentation Improvement Program

This CDI program contains three (3) self-paced online courses directed toward clinical documentation specialists or related roles in healthcare settings. This is a useful program for coding professionals; however, the courses focus on documentation assessment and improvement as they support for code assignment (the program does not contain any training on how to code for reporting or indexing).

The following general information applies to all three courses in this program:

Prerequisites: No academic prerequisites
Textbooks: None required. All course material presented online
Credits:    An AHIMA Certificate of Completion and two (2) CEUs will be awarded upon successful completion of each course.
Classes Begin: When payment is received and processed
Class Access Period: 8 weeks, beginning on date of enrollment

Clinical Documentation Improvement: Issues

The intention of this course is to introduce HIM professionals to the exciting new world of Clinical Documentation Specialists. Within this course, professionals will learn about important skills and areas of knowledge that will assist them in becoming successful Clinical Documentation Specialists. The objectives of this 6-lesson course are to:

  • Discover what are Clinical Documentation Specialists (CDS) and necessary skill sets for CDS’
  • Discuss necessary coding skills and knowledge about the MS-DRG system needed to be a successful CDS
  • Evaluate methods of communication with physicians and promote new ways of communication
  • Discuss specificity and the reason for the necessity of concrete documentation in the medical record
  • Examine how minimal documentation can affect potential reimbursement
  • Identify best queries and value the physician as part of the query process

Clinical Documentation Improvement: Program Success

This two CEU, six lesson course will review overall aspects of managing a clinical documentation improvement (CDI) program. Planning and organizing the program is essential for success, as is monitoring and evaluation. The course also covers potential legal aspects involved with the query process, with the goal of querying for both reimbursement and data quality. Effective management involves hiring and retaining qualified staff, which is also addressed. The objectives of this 6-lesson course are to:

  • List the data necessary to sell a Clinical Documentation Improvement Program
  • Assemble a team of key players and explain the factors in the design and implementation of a CDI program
  • •Identify who to hire as the CDI specialist, define their role, identify when and where to begin
  • Explain how to get buy-in from the physicians. Discuss communication barriers and Identify Educational Opportunities
  • Describe the concurrent review process and create an effective query
  • Illustrate how to measure the success of the CDI program and the effectiveness of the CDI Specialist

Clinical Documentation Improvement: Quality Measures and Documentation Standards

This 2-CEU, 6-lesson course will review how clinical documentation improvement (CDI) programs relate to quality measures in addition to being in an electronic environment. As the industry requires an increase in reporting quality measures in addition to documentation standards, it is important for an HIM professional to understand the impact CDI programs may have on a facility’s data. This course will review how CDI will affect documentation necessary to meet industry standards, as well as report cards. The objectives of this course are:

  • Identify how documentation affects quality measure reporting
  • Differentiate various organizations' documentation standards
  • Examine how coded data affects quality outcome report cards
  • Examine best practices in ensuring data quality in electronic environment

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