Clinical Documentation Improvement

HP3 has developed a substantial Clinical Documentation Improvement (CDI) program to assist our clients in providing documentation in the medical record that is complete and accurate. HP3’s CDI tools and education positively impact the quality and quantity of physician documentation in the medical record at the point of service. Since clinical documentation is the primary driver for a hospital’s case mix index (CMI), every hospital should develop a CDI program that will properly reflect the acuity of the patients the hospital treats.

Our CDI programs are focused on clinical documentation at the point of service while the patient is still in the hospital. CDI programs are guided by official coding guidelines and pertinent governmental and regulatory requirements. HP3 tailors the CDI program to the specific health system to ensure eventual support of the physicians and the non-physician clinicians. The program incorporates principles of physician professional fee documentation, coding and billing, as well as hospital-based principles.

The goals of an HP3 CDI program are to ensure clinical documentation:

• Drives appropriate code selection for accurate reimbursement.
• Supports high quality care.
• Reflects patient acuity levels.
• Is accurately and compliantly captured at the point of service.
• Meets JCAHO standards for clinical documentation.
• Reduces risks from incomplete or unclear documentation.
• Provides accurate data for Medicare and other quality indicators and hospitals.

HP3 is able to supply our clients with valuable data analysis from the onset of the program and continues through the follow-up process:

• Initial CDI Assessment: Initial medical record assessment to improve your documentation and deliver optimum results.
• Clinical Documentation Specialist (CDS) Education and Shadowing: HP3's comprehensive CDS education program and peer-to-peer on-unit real time assessment of the documentation specialist's/case manager’s proficiency.
• CDI Physician Training: HP3's specialty-based documentation training for physicians.
• CDI Education: HP3's comprehensive training program designed for non-physician clinicians can be delivered on-site or as an e-learning program through HP3U™.
• CDI Monitor: Assists hospital staff in monitoring the status of the CDI program. This tool provides summary impact reports and financial results.
• CMI Navigator™ Data Analysis: Assists in determining if your hospital’s revenue cycle is accurate and healthy. This tool uses a predictive model based on national norms and HP3’s experience to identify opportunities for improved documentation.
• Physician Documentation Survey: Web-based survey system that analyzes physicians' opinions about CDI during every phase of the program.

HP3 tools to support our CDI program:

• Doc Notes™
• Doc Templates™
• DRG Navigator™
• Doc Pocket Tools™
• CDI Physician Handbook™