The importance of clinical documentation improvement for Australian hospitals

Author:

Hay Patricia1,Wilton Kathy1,Barker Jennifer1,Mortley Julie1,Cumerlato Megan23

Affiliation:

1. 3M Health Information Systems, Australia

2. Health Information Management Consultant, Australia

3. NCCH, University of Sydney, Australia

Abstract

Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in “real time” so that it is fit for reporting, analysis and reimbursement. Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment.

Publisher

SAGE Publications

Subject

Health Policy,Leadership and Management

Reference17 articles.

1. Australian Commission on Safety and Quality in Health Care (ACSQHC) (2017b) Improving Documentation at Transitions of Care for Complex Patients. Sydney, NSW: ACSQHC, pp. 3, 26.

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