- Scope: This focuses on the ability of physicians to document patient care thoroughly, accurately, and in a way that complies with clinical guidelines and regulations. It refers to how well a physician can translate their clinical decision-making, diagnostic reasoning, and treatment plans into documentation that reflects the complexity of patient care.
- Skills: Physicians need to ensure their documentation: Accurately represents the patient's condition, diagnoses, treatments, and progress. Meets the legal and billing requirements. Supports proper coding for reimbursement. Provides clarity for other healthcare providers and continuity of care.
- Goal: Achieving "physician documentation excellence" often means improving the quality, specificity, and completeness of the physician's clinical notes.
2. Clinical Documentation Improvement (CDI) Specialists:
- Scope: CDI specialists are professionals with expertise in clinical documentation who work to enhance the overall quality and accuracy of healthcare records. They typically focus on ensuring that documentation reflects the true clinical picture of the patient and supports proper coding and reimbursement practices.
- Role: CDI specialists are not responsible for directly providing patient care, but they: Review clinical documentation for accuracy and completeness as primarily relates to diagnoses, coding, billing, and capture of quality measures Collaborate with physicians and other healthcare providers to clarify any discrepancies or areas where documentation might be lacking. Ensure that the documentation captures the severity of illness, risk of mortality, and other key factors that impact coding and reimbursement. Help physicians and other providers understand how their documentation impacts coding and billing.
- Goal: The goal of CDI specialists is to improve the documentation to ensure it fully supports the clinical picture, supporting and leading to more accurate coding, compliance with regulatory standards, and appropriate reimbursement.
Why Physicians Achieve "Physician Documentation Excellence" vs. CDI Specialists:
- Focus on Clinical Care vs. Documentation Quality: Physicians' primary focus is on delivering patient care, and they often document their findings, decisions, and plans quickly in clinical notes. Their responsibility is to ensure that the documentation is accurate and complete from a clinical perspective. On the other hand, CDI specialists focus on ensuring that documentation is aligned with coding and reimbursement rules and that it fully represents the clinical care provided.
- Collaboration, Not Replacement: While both physicians and CDI specialists aim for high-quality documentation, the physician's role is about clinical accuracy, and the CDI specialist's role is to ensure that the clinical documentation meets the necessary standards for coding, billing, and regulatory requirements. Thus, while a physician can achieve "documentation excellence," a CDI specialist is working to improve the entire documentation process across all healthcare providers, documentation that optimizes coding, billing, and reimbursement.
In essence, "physician documentation excellence" is about mastering the clinical aspects of documentation, whereas CDI specialists focus on improving the quality of documentation to meet regulatory and financial needs. Both roles are complementary but focus on different aspects of the documentation process. Artificial Intelligence-driven documentation tools and processes enable more effective and complete physician documentation, the CDI profession must realize and capitalize upon the need to pivot away from their current role consisting of “documentation integrity.” The CDIS of the not-distant future will support the migration to AI-enabled documentation, serving as educators and auditors that ensure the accuracy and completeness of documentation. There will always be opportunities for physician documentation improvement, working with AI to help physicians achieve documentation excellence. While AI can assist physicians capture the essence of the patient encounter and care provided, there will always be a requirement to review records and provide feedback to physicians on strengthening of the note. The real question is whether the CDI profession acknowledges the requirement for role transition in healthcare with situational awareness or will they cling to the status quo?
