Clinical documentation: Paving the path to an accurate, complete medical record

TMC’s CDI experts (from left): Shelley Alimena, Susan Tipton, Patrice Kleber and Heidi Heinrich.

A team of nurses working in TMC Case Management are joining in the celebration of the nation’s first Clinical Documentation Improvement Week, Sept. 18-24.

Clinical Documentation Improvement (CDI) specialists review patient medical records to determine whether all conditions and treatments are documented. Proper documentation paints an accurate picture of a patient’s illnesses, to set the stage for appropriate care and correct coding.  When the documentation is unclear or deficient, CDI specialists prompt physicians to provideclarification.

 “The goal of Clinical Documentation Improvement Week is to increase awareness of the CDI profession and honor CDI specialists for the hard work they perform every day,” says Brian Murphy, director of the Association of Clinical Documentation Improvement Specialists.

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