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A STRONG CLINICAL documentation improvement (CDI) pro-gram begins with the proper recruitment, careful selection, and adequate orientation of CDI specialists. The purpose of a CDI program is to initiate concurrent and retrospective reviews of health records for conflicting, incomplete, or nonspecific pro-vider documentation. These reviews usually occur on the pa-tient care units. The goal is to identify accurate clinical indica-tors to ensure that the diagnosis and procedures are supported byICD-9-CM codes.
These efforts result in greater integrity of the documentation, coding, reimbursement, severity of illness, and risk of mortality classifications. Defining the goals of the CDI program as well as the purpose of the CDI specialist's role within the organization will assist providers in developing a process designed to consis-tently hire quality staff.
Individuals qualified to serve as a CDI specialist include, but are not limited to, health information management (HIM) pro-fessionals, coding professionals, physicians, nurses, and other professionals with a clinical and/or coding background. In this diverse population of possible candidates, having an appropri-ate knowledge base is just one piece of the overall process and does not alone guarantee success. This practice brief will pro-vide guidelines for the ideal successful recruitment, selection, and orientation processes for CDI specialists in the develop-ment of a sustainable and high quality CDI program.
Recruitment Best Practices
Hiring and retaining the best talent in healthcare is as tough as it's ever been. According to a study by the National Associa-tion of State Auditors, Comptrollers and Treasurers, for the first time in US history the number of young workers entering the labor market will not be enough to replace an aging workforce. Recruiting experienced professionals for CDI programs has be-come an important skill for managers today.
In March of 1999, the Cecil G. Sheps Center for Health Ser-vices Research (Sheps Center) at the University of North Caro-lina at Chapel Hill presented a proposal to the Council for Allied Health in North Carolina to establish advisory panels that ex-amine the allied health workforce. In 2002, the Technical Panel of the council met to further discuss HIM workforce trends. The panel determined that the HIM workforce has undergone nu-merous changes over the last 50 years. The profession, once lim-ited to medical records management, has expanded and is now closely linked to new...