Clinical Documentation Improvement Certificate

Person working on tablet with health forms overlayed with data

Specialization in this in-demand field is on the rise. Are you an RN, LPN, RHIT, RHIA or CCS, CCS-P, CPC, CIC, COC, CPMA? Clinical Documentation Improvement uses your skills in medical coding, clinical care and health record documentation. This Certificate’s curriculum covers the CDIP exam domains and will prepare students for taking the CDIP exam.

Acceptance into this program requires an associate's degree and one of the following credentials: RHIA, RHIT, RN, LPN, CCS, CCS-P, CPC, CIC, COC, CPMA. 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.

  • BIO 212 Anatomy and Physiology

    3 credits
  • BIO 215 Pathophysiology

    3 credits
  • HCA 105 Medical Terminology

    3 credits
  • HIM 205 Reimbursement Methodologies

    3 credits
  • HIM 210 Clinical Classification Systems I

    3 credits
  • HIM 211 Clinical Classification Systems II

    3 credits

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.

  • HIM 371 Revenue Cycle and CDI

    3 credits
  • HIM 373 CDI Operational Process

    3 credits
  • HIM 475 Compliance and Medical Necessity

    3 credits
  • HIM 477 Mastering Documentation

    3 credits
  • HIM 491 CDI Case Study Practicum

    3 credits
  • Total

    33 credits

Outcomes & Pathways

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.

Why Charter Oak State College?

  • 100% online
  • Credit for credentials
  • Six (6) start dates
  • Expert Faculty