How Clinical Documentation Improvement Boosts Quality of Care

Medical transcription outsourcing plays a critical role in ensuring accurate, timely and complete documentation in the electronic health record (EHR).  In fact, success with clinical documentation improvement (CDI) begins with efficient EHR data entry to ensure complete, precise and accurate capture of the patient encounter and services provided. Efficient clinical data capture and documentation is essential to promote quality patient care in today’s value-based environment.

Clinical Documentation Improvement Boosts Quality of Care


Why is CDI so vital for patient care? One reason is that patient care depends on efficient communication among healthcare providers. As an AHIMA article notes, the patient’s condition can change abruptly, and communicating and documenting changes and resulting responses is necessary to prevent “missteps” in care. The report notes that failure to document properly can lead to the following problems for the patient:

  • Being overcharged or not covered for treatment that may have been necessary
  • Being wrongly categorized as being less sick because aggregated diagnoses do not reflect severity of illness
  • Face a higher risk of developing complications of care since acuity of symptoms are not described
  • Face increased chance of readmission after discharge if the appropriate treatment plan was cut short or weekend follow-through lapsed due to short staffing

In an article published in the Journal of AHIMA in 2013, University of Pittsburgh Medical Center’s Adele Towers, MD, MPH stressed that CDI  is necessary improve every aspect of patient care and hospital management.

“The main message to physicians should be that CDI is a quality initiative,” she wrote. “When asking physicians why good clinical documentation is necessary, they will most likely say that it is to document the care of the patient and to communicate with other providers. Physicians understand the need to make documentation legible, timely, complete, precise, and clear. They understand that the documentation is the legal health record”, said Towers (

Therefore, CDI specialists should focus on the quality, accuracy, and completeness of documentation. “Quality and completeness” can be defined as:

  • A logical record that clearly, concisely, and consistently reflects the patient’s chief complaint in his or her own words.
  • A history of present illness (HPI) which is an accurate description of the development of the patient’s present illness.
  • The nature of the chief complaint, including the severity of illness equating to the intensity of service.
  • Physical exam in agreement with the HPI and congruent with the assessment and plan.
  • Complete description of patient assessment, reasons for admission and tests conducted.
  • An assessment that coincides with and is traceable back to the HPI.
  • Focus on maintaining accurate documentation during care transitions and across all care settings.
    According to a white paper titled ‘An Essential Guide to Clinical Documentation Improvement”, other fundamental features of accurate and complete documentation include:
  • Confirmation of test results and resultant treatment provided or changes in dose, including any corresponding conditions for which the treatment is being provided.
  • Documentation supporting the Most Responsible Diagnosis (MRDx) (which may not be the reason the patient sought medical attention), comorbidities (both present upon admission and those developed post-admission), and interventions performed.
  • Clarity on whether the condition is a complication of surgery or any changes in diagnosis during the course of their stay.
  • Legible, consistent, complete and precise documentation with full dates and signatures on all documentation (to ensure that the health record meets legal standards).

The key players in the CDI process are physicians, medical coders, CDI specialists and medical transcription companies. Besides improving quality of care, investing in CDI offers financial benefits. According to a 2016 report from Black Book Market Research, CDI implementation led to gains of at least $1.5 million in appropriate healthcare revenue and claims reimbursement for 90 percent of hospitals with more than 150 beds. The researchers also noted that CDI promoted appropriate and timely reimbursements from payers, and helped avoid costly penalties for non-compliance.

Ensuring accurate EHR data entry is critical for CDI implementation. However, the structured format and drop-down menus of EHR systems often fail to capture all the nuances of the physician-patient interaction. A 2016 American Medical Association (AMA) study also found that physicians spend 27 percent of their work time on direct patient interactions, and about 49 percent on EHR documentation. Providers also spend an average of two hours on EHR data entry outside of their office hours.
Outsourcing medical transcription is a practical option to optimize EHR data entry, and promote usability and clinical efficiency.  Medical transcriptionists document physician dictation records accurately and CDI specialists can use the transcripts to detect gaps that need to be filled to ensure that the most specific medical codes are used. Medical transcriptionists also relieve physicians of their EHR data entry and administrative tasks that encroach on the physician-patient time that is central to effective care.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.