Clinical Documentation Integrity

Guidance on creating and maintaining accurate clinical documentation, which lends itself to proper reimbursement, public health data, disease tracking, and more.

Clinical Documentation Integrity (CDI) TOOLKIT for New Leaders (2024)

This CDI Toolkit for New Leaders will address the various topics that will aid leaders in proactively addressing the unique challenges the come along with focusing on the success and sustainability of a CDI Department. Whether aspiring to move into a management role or looking for ways to further increase your current leadership skillset, the intent of this toolkit is to provide a foundational knowledge base to address common CDI leadership challenges.

Prospective Clinical Documentation Integrity (CDI) Reviews And Query Alert Practice Best Standards

The goal of this Prospective CDI Reviews and Query Alert Practice Best Standards is to provide best practices relating to prospective reviews and to recognize that there is a difference between documentation alerts/notifications designed to influence a provider’s documentation versus a clinical alert/notification for clinical decision making at the time of charting by a provider. In most instances, these terms may be used interchangeably without realizing that they are two very different things.

AHIMA Inpatient Query TOOLKIT (2019)

The Inpatient Query Toolkit benefits the hospital’s compliance with billing/coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals. Proper responses to queries result in improved accuracy and completeness in documentation, coding, reimbursement, as well as severity of illness (SOI) and risk of mortality (ROM) classifications.

AHIMA Outpatient Query TOOLKIT (2019)

As healthcare continues to evolve with a stronger focus on containing the costs of quality care across the
continuum of care, CDI and the art of querying are now expanding beyond the inpatient setting to include
hospital outpatient clinics, physician clinics, emergency departments, ambulatory surgery centers, hospital
observation, and other outpatient care settings. Therefore, providers across the healthcare spectrum need
to be educated about the importance of documentation improvement through AHIMA Outpatient Query Toolkit.

CDI TOOLKIT for Beginners (2021)

A CDI toolkit is useful not only to the professionals who work in CDI but also helpful to physicians, hospital administrators, health information management (HIM) professionals, nursing staff, and others in a variety of healthcare setting. This beginner's toolkit will benefit those professionals who are new to CDI.

Clinical Documentation Improvement TOOLKIT (2016)

A CDI toolkit is useful not only to the professionals who work in CDI but also helpful to physicians, hospital administrators, health information management (HIM) professionals, nursing staff, and others in a variety of healthcare setting.

Guidelines for Achieving a Compliant Query Practice

The industry gold-standard AHIMA/ACDIS practice brief provides best practices for professionals in all healthcare settings who participate in query processes.

Provider Query Templates Simplified

Boost Workflow Efficiency, Accelerate Proper Reimbursement, and Ensure Compliance with AHIMA CDI Query Templates

Unlock the power of electronic, standardized provider query templates designed to work with leading EHR systems. Complete the form to see the list of more than 180 templates available across inpatient, outpatient, long-term care, and pediatric settings.

Clinical Validation Practice Brief

Improve Accuracy, Consistency, and Collaboration in Clinical Validation. Download the practice brief.

Developing Facility-Specific Coding Guidelines (2023)

This Practice Brief can be used to walk through various diagnosis and procedure considerations to assist organizations in developing robust facility-specific coding guidelines. It includes basic guidance as well as insights into the preparation and decision-making process.

Clinical Documentation Integrity Key Performance Indicators

This Practice Brief is focused on the key performance indicators (KPIs) that can be evaluated to measure the performance of clinical documentation integrity (CDI). KPIs are measurements specific for an organization or department being evaluated. KPIs are critical to track progress toward an intended result.

Ethical Standards for Clinical Documentation Integrity (CDI) Professionals (2020)

The AHIMA Ethical Standards for Clinical Documentation Integrity Professionals are intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals' commitment to integrity.

Clinical Validation: The Next Level of CDI (2019)

The clinical validation process has become a very challenging task for most healthcare organizations, so it is important that each organization uses industry guidance to create their own policy and procedure related to the clinical validation process in both the inpatient and outpatient settings.

Best Practices in the Art and Science of Clinical Documentation Improvement (2018)

The discipline of clinical documentation integrity (CDI), whether practiced by clinicians or coding professionals, has the potential to deliver great value to the healthcare system—including to the patient, who deserves a clear, concise, consistent, and accurate health record to support continuity of care.

Measuring the Value of the Certified Documentation Improvement Practitioner (CDIP) Credential (2018)

This Practice Brief will outline the benefits of the CDIP credential to assure organizations and providers that their CDIP-credentialed staff are working to ensure clinical information supports clinical care, treatment, coding guidelines, and reimbursement methodologies.

Impact of Physician Engagement on Clinical Documentation Improvement Programs

This Practice Brief discusses the impact of physician engagement on clinical documentation integrity programs.

Using Medical Scribes in a Physician Practice

This Practice Brief will explore some of the benefits and challenges of scribes within the physician practice setting.