In this course, students will study the principles of chart review along with clinical concepts to identify gaps in documentation. The goal will be that students will understand documentation provider clarifications and the key elements of the CDI process. Defining, developing and acquiring CDI staff skill sets, core competencies and knowledgebase promoting achievement of clinical documentation excellence will be explored. Students will learn the CDI tools, metrics and key performance indicators, and how to effectively develop provider education.
- BIO 212: Anatomy and Physiology
- BIO 215: Pathophysiology
- ENG 101: English Composition 1
- ENG 102: English Composition 2
- HCA 105: Medical Terminology
- HIM 205: Reimbursement Methodologies
- HIM 210: Clinical Classification Systems I
- HIM 211: Clinical Classification Systems II
Student Learning Outcomes (SLOs)
Upon successful completion of the course, the student will be able to:
- Differentiate the seven characteristics that constitute quality documentation
- Explain ethics and compliance in clinical documentation integrity.
- Interpret the chart review process and identify documentation gaps.
- Identify concurrent conditions, major concurrent conditions, and severity of illness diagnosis in the medical record.
- Analyze documentation deficiencies that require provider clarification.
- Construct a compliant non-leading query.
- Explain basic clinical criteria for common problematic diagnoses: sepsis, acute kidney failure/injury, chronic kidney disease, respiratory failure, encephalopathy, and malnutrition.
- Describe the importance of clinical validation.
- Examine data, metrics, and key performance indicators (KPI) used in CDI programs.
- Describe the importance of developing physician/provider relationships to promote provider engagement and education.
General Education Outcomes (GEOs)
Course Activities and Grading
Discussions (240 pts, Weeks 1-8)
Quizzes Weeks (140 points, Weeks 1-7)
Case Study (100 pts, Week 1)
Assignments (420 points, Weeks 2-8)
Final Exam (100 points, Week 8)
Available through Charter Oak State College's online bookstore
- Hess, P.C. (2015). Clinical documentation improvement: Principles and Practice. 1st. ed. AHIMA, American Health Information Management Association ISBN-13: 978-1-58426-502-3
Students must have an active AHIMA membership to access some of the required reading. If you have never been an AHIMA member and do not have an AHIMA credential, you will be able to apply for the Student Membership.
Readings and Exercises
Topic: Clinical Documentation: Medical Record Review and Documentation Sources
Topics: Problematic Diagnoses and Clinical Validation
Topics: Concurrent Conditions, Major Concurrent Conditions, and Severity of Illness Diagnoses and Reimbursement Impact
Topics: Medical Record Review and Physician/Provider Clarification
Topics: Physician Collaboration & Training
Topic: Data Analysis
Topic: CDI Metrics and Key Performance Indicators
COSC Accessibility Statement
Charter Oak State College encourages students with disabilities, including non-visible disabilities such as chronic diseases, learning disabilities, head injury, attention deficit/hyperactive disorder, or psychiatric disabilities, to discuss appropriate accommodations with the Office of Accessibility Services at OAS@charteroak.edu.
COSC Policies, Course Policies, Academic Support Services and Resources
Students are responsible for knowing all Charter Oak State College (COSC) institutional policies, course-specific policies, procedures, and available academic support services and resources. Please see COSC Policies for COSC institutional policies, and see also specific policies related to this course. See COSC Resources for information regarding available academic support services and resources.