Clinical Documentation Improvement: Increasing in Utility, Importance, and Integrity

This is an excerpt from HFMA’s May 2018 article featuring James P. Fee, M.D., CCS, CCDS. Click here for the full article.

Clinical documentation has long been at the heart of any regimen of patient care. An accurate and thorough record of a patient’s health and medical history that includes notes covering all interactions, diagnoses, and treatments gives healthcare providers a quick tool for understanding a patient’s current condition and a powerful tool for determining a path forward. But today, it also can do much more.

“The ‘I’ in CDI has become integrity—rather than improvement—because the goal is not so much improving documentation as it is focusing on data integrity.”

–James P. Fee, M.D., CCS, CCDS