Clinical Documentation Improvement Program

The Clinical Documentation Improvement Program (CDIP) is committed to educating and supporting providers in documenting ‘excellent’ patient care.

Excellent clinical documentation supports medical necessity, length of stay, accurate severity of illness and risk of morbidity and mortality reporting, reduces payer denials, ensures the appropriate credit for resource consumption and the complexity of care provided to our clinical patients.

The Clinical Documentation Specialists (CDS) are a dedicated team of medical professionals with years of clinical experience and advanced education related to complete and compliant provider documentation.

The CDS concurrently reviews inpatient medical records to assist with obtaining the specificity of documentation needed for accurate coding and reporting. When more specificity of diagnoses and procedures are needed, the CDS will query the provider for more specific documentation based on currently documented information: risk factors, clinical indicators and treatment/monitoring. 

Queries are posed to the individual providers via the electronic medical records communication system and require the provider to respond by documenting their clinical determination in the current progress notes and/or the discharge summary. If you have any questions or concerns related to a query please contact the CDS using the contact information that is located at the bottom of every provider query.

We will be contacting you to arrange a brief new provider orientation to CDIP. We look forward to partnering with you when we meet and when we round the hospital units.