What do we really want from clinical documentation improvement programs?

Abstract

Clinical documentation improvement (CDI) roles are being increasingly created in Australian hospitals. It is important to understand what good clinical documentation is and who is responsible for it as well as what these roles potentially offer our health system. This article explores the role of a CDI specialist, the benefits and pitfalls of clinical documentation improvement programs, and mounts an argument that health information managers and clinical coders are uniquely placed to fill these roles in Australian hospitals.