Clinical Documentation Improvement

1 Module 1: fundamentals of clinical documentation

2 Topic 1.1: Fundamentals of clinical documentation / Criteria for high quality clinical documentation

3 Topic 1.2: Types of Clinical documentation / Sources of clinical documentation / Author of clinical documentation / A preference for the inpatient acute Care setting

4 Topic 1.3: The translation of clinical documentation in coded data

5 Topic 1.4: Assessing clinical documentation

6 Topic 1.5: Moving forward with A CDI program / Key decision makers / Clinical documentation improvement program / Program committees / Communicating to the organization / Customizing the CDI program / New and refreshed CDI program / Management of existing CDI program

7 Module 2: Clinical documentation program implementation

8 Topic 2.1: Implementing clinical documentation program / Staffing the program / physician, nonphysician clinician, and CDI program staff training

9 Topic 2.2: Documentation Review and physician queries

10 Topic 2.3: Collecting, Analyzing, and reporting on program data & ensuring CDI program compliance

11 Module 3: The process of expanding and improving a clinical documentation program

12 Topic 3.1: Continual CDI program renewal & CDI best practices: operational and financial

13 Topic 3.2: Clinical documentation improvement technology and synergies with the Electronic Health Record

14 Topic 3.3: Clinical documentation improvement: Multidisciplinary team approach

15 Topic 3.4: Growing the clinical documentation improvement program in all patient care areas

16 Topic 3.5: Critical thinking

1.1 Mapped to: K1 - k2

Reviews fundamentals of clinical documentation

Teaching Strategy Interactive Academic lectures