Healthcare IT News: Clinical Documentation

Clinical documentation (CD) is the formation of a digital or analog record reflecting a medical treatment, medical trial, or clinical test. Optimal clinical documentation helps in providing quality care and optimizing revenue cycle management in hospitals and health systems, which are thriving under value-based reimbursement. Clinical documentation improvement (CDI) is a process of improving medical data collection to maximize claims reimbursement revenue and enhance the quality of care. CDI programs reassure that the medical record documentation presents an appropriate picture of the patient's diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care.