AHIMA: Poor documentation risky to patient health

Clean, granular and accurate data is the foundation for many other information technology processes and procedures, which underscores the need for good clinical documentation. That's the assertion in an article published in the July issue of the Journal of AHIMA, “Reinventing CDI." The story analyzes the trend of organizations relaunching and reworking data integrity efforts with clinical documentation improvement (CDI) programs. “Clinical documentation is at the core of every patient encounter,” said AHIMA CEO Lynne Thomas Gordon, MBA. “Health information management (HIM) professionals should continue to use their skills, expertise and leadership to improve the CDI process, which will help organizations collect and provide meaningful information throughout the continuum of care.” CDI programs can be a provider’s first line of defense to make sure they are meeting the audit and quality program requirements and ensure they are being paid appropriately for their services. Sound CDI practices also contribute to information governance efforts because they involve the creation of reliable, complete and authentic health information, according to Lydia Washington, MS, a senior director of HIM practice excellence at AHIMA. “As we start to think of these (concepts) from different perspectives and perhaps more strategically, such as not only the implications for payment but also things like coordination of care or patient engagement, we can see that poor documentation has far-reaching implications,” Washington said. “This broader view is what makes information governance different from how we may have thought about CDI in the past.”