Connecticut State Colleges and Universities
Charter Oak State College Official Catalog

Certificate in Clinical Documentation Improvement

This certificate is designed for adult learners who already have a minimum of an Associate’s degree along with 1-2 years of related experience, who want a specialized certificate to increase their opportunities for employment in CDI.  Acceptance into this program also requires one of the following credentials: RHIA, RHIT, RN, LPN, CCS.  This certificate equips students with a working knowledge of clinical documentation improvement (CDI) tasks, procedures, policies, philosophy, and value.  A focus will be placed on mastering documentation concepts as it relates to reimbursement and medical necessity.  Courses will immerse students in real-world scenarios and processes, giving the student experience that simulates work experience in the field.  A case study practicum is the final course and will require students to demonstrate high-level CDI knowledge and skills.

This Certificate is 33 credits and 15 of these credits must be completed at Charter Oak.  All courses must be completed with a grade of 'C' or better.

Certificate Core Prerequisites

BIO 212: Anatomy and Physiology

3cr

BIO 215: Pathophysiology

3cr

HCA 105: Medical Terminology

3cr

HIM 205: Reimbursement Methodologies

3cr

HIM 210: Clinical Classification Systems I

3cr

HIM 211: Clinical Classification Systems II

3cr

Certificate Core Courses

 Revenue Cycle and CDI

3cr

 CDI Operational Process

3cr

 Mastering Documentation

3cr

Compliance and Medical Necessity

3cr

CDI Case Study Practicum

3cr

Total

33cr

Student Learning Outcomes

Students who complete a certificate in Clinical Documentation Improvement will be able to:

  1. analyze coded diagnoses and procedures related to reimbursement methodologies and billing;
  2. analyze patient health records in the current EHR environment for documentation that meets accepted coding guidelines;
  3. query physicians for documentation clarification and interpretation;
  4. identify ethical, legal, and compliance issues as they relate to documentation, coding and reimbursement;
  5. evaluate the relationship between financials and clinical documentation that drives the operational revenue cycle performance;
  6. utilize the principles of chart review and clinical documentation improvement tools within the EHR;
  7. relate medical necessity to the criteria for quality documentation and communication of patient care and bidirectional clinical indicators;
  8. demonstrate the ability to communicate, interact, and engage providers in the standards of documentation as an integral part of the practice of medicine.

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