Name : Gita Fitrisia

Registration number : 20160310009

Introduction
Good morning my friends. My name is Gita Fitrisia. My registration
number is 20160310009. I come from Faculty of Health Sciences, majoring
Health Information Management. First of all, I want to say thanks to Miss Nargis,
next I say thanks to all my friend.

This moment I’d like to talk about Clinical Documentation Improvement

(CDI). I choose this topic, because there are many people don’t know about CDI.

In the first part of my presentation, I’ll describe about the concept of

CDI, after that I’ll talk about importance of CDI, then I’ll explain about seven
criteria for high-quality clinical documentation. Finally I’ll talk about the clinical
documentation specialist.

Before I stop my presentation, I will take some conclusions. I will be hapy

if you ask me at the end of my presentation. Let me start.

Body
1. Concept of Clinical Documentation Improvement
A clinical documentation program staffed by clinical
documentation specialist. The ultmimate purpose of a CDI program is to
ensure that physicians provide the most complete, clear, reliable, timely,
legible, and precise documentation (information) consistent with the
clinical findings (data) in the medical record. A CDI program includes
review of patient records while the patient is still in the hospital to
concurrently identify any opportunity for improvement in clinical
documentation.

2. The Importance of Clinical Documentation

Clinical documentation is any manual or electronic notation (or
recording) made by a physician or other healthcare clinician related to a
patient’s medical condition or treatment. Clinical documentation is the
primary menas clinicians use to communicate their opinions about a
patient’s condition(s) and decisions about how treat the patient.

Clinical documentation is important because clinical

documentation in patient health records is highly regulated, the theory
must begin with regulatory and legal requirements. Medicare Conditions
 of Participation require all healthcare providers to maintain patient health
records and dictates certain content.

3. Seven Criteria for High-Quality Clinical Documentation

The seven criteria for hight-quality clinical documentation required that all
entries in the patient record be:
1. Legible : clear enough to be read and easily deciphered
2. Reliable : Trustworthy, safe, yielding the same result when repeated
3. Precise : Accurate, Exact, Strictly Defined
4. Complete : Has the Maximum Content
5. Consistent : Not Contradictory
6. Clear : Unambigous, Intelligible; Not Vague
7. Timely : At the Time of Service

4. The Clinical Documentation Specialist

Clinical documentation specialist is the individual who is chiefly
responsible for reviewing the patient’s record to determine whether it
meets the criteria for high-quality clinical documentation. Clinical
documentation specialist must have strong skills in the following four
areas:
1. Healthcare regulations, including reimbursement and
documentation requirements
2. Clinical knowledge with training in pathology of disease
processes
3. Ability to read and analyze all information in a patient’s health
record
4. Communication with physicians and other clinicians.

Conclusion
1. Clinical Documentation Improvement (CDI) is a program include review
any opportunity for improvement in clinical documentation
2. Clinical documentation is important because clinical documentation in
patient health records is highly regulated, the theory must begin with
regulatory and legal requirements
3. The seven criteria for hight-quality clinical documentation are legible,
reliable, precise, complete, consistent, clear and timely.
4. Clinical documentation specialist is the individual who is chiefly
responsible for reviewing the patient’s record to determine whether it
meets the criteria for high-quality clinical documentation.