Clinical documentation improvement (CDI) means documenting so that coding and payment accurately reflect the care. When documentation is vague or missing, you leave money on the table or trigger audits.
What to document
Specific diagnoses, functional status, and the need for each discipline and visit frequency. “Patient has diabetes” is weak; “Patient has Type 2 diabetes with recent A1C 9.2, on insulin, requires nursing for medication management and teaching” is better. Visit notes should support the plan and the codes you’re billing. Run visit note QA that prevents denials before billing so payers see the right support.
Quick wins
Train clinicians on the link between documentation and payment. Do a chart review: do the notes support the primary and secondary diagnoses? Are there missed opportunities to capture complexity? DONs who own CDI often run a monthly sample review and feed findings back to staff,so improvement is continuous, not just at audit time. We have a CDI quick reference you can download: what payers and auditors look for and a short review checklist. Use the button below to get it.