Document Type

Research Project

Publication Date

Spring 4-16-2018


The world of technology in the twenty first century is forever expanding. In the healthcare field, patient data has transformed from paper charts into electronic health records. Electronic health records allow for organized patient information however, an enormous amount of information becomes available. Sometimes the massive amount of information is not always needed but important detail the medical chart is looked for by insurance companies for reimbursement. There is a special department in hospitals called the Clinical Documentation Improvement specialists who are made up of experienced medical coders, registered nurses, mid-level practitioners such as nurse practitioner’s s or physician’s assistants and physicians. This team focus on the pertinent clinician documentation while the patient is hospitalized looking for accurate information depending on the patients diagnose/s and reducing low quality clinical records. The importance of precise patient information leads to the point of this project to demonstrate the value of clinical documentation improvement.