A CDI program's purpose: Documentation for care quality

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI

The overarching goal of a documentation improvement program is not to improve reimbursement for the hospital, but to effect a positive change in the behavior of those who document in the medical record. This change in documentation detail and scope is necessary because healthcare is gravitating toward value of services, rather than the traditional model of paying for volume. It’s quality divided by cost. Spending more money on a patient does not mean the care provided is any better, as evidenced by the work of the Dartmouth Atlas project (visit its website at www.dartmouthatlas.org). It boils down to the patient and how much “medically necessary care” as supported by the physician’s clinical documentation is required to treat that patient, and the efficiency of the physician in managing the patient’s clinical condition.