How to Become a Clinical Documentation Improvement Specialist

Accurate and complete documentation is important in the health care industry. Without proper processes and attention to detail, medical records can complicate billing and impact patient care. That’s why many organizations employ clinical documentation improvement (CDI) specialists, also known as clinical documentation integrity specialists, to ensure that medical records are complete and precise.

To learn more about CDI, we spoke with Earshler Taylor, faculty member in the Purdue Global School of Health Sciences. Read on to learn about CDI, why it’s important, and how to begin your career.

What Is Clinical Documentation Improvement?

Within the context of the CDI profession, clinical documentation refers to the notes or entries that a clinician or a provider makes within a patient's medical record based on a patient visit. At times, these notes may not tell the full story about a patient's health history or current status. However, the accuracy — and completeness — of this information is vital for billing and hospital quality metrics.

The American Health Information Management Association (AHIMA) states that clinical documentation should be "clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient’s disease burden and scope of services provided." The goal of CDI is to ensure that clinical documentation meets these criteria.

According to Taylor, CDI is commonly called clinical documentation integrity because it better reflects what the practice is about: ensuring accurate recordkeeping — not just for revenue but also to support patient care.

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What Is a CDI Specialist?

AHIMA states that a CDI specialist ensures that the quality of clinical documents meets all requirements at every level of care. This person analyzes health information and shares their insights with the organization, identifying areas where the facility or a provider could use support.

"Their primary task is to review medical records for deficiencies or conflicting documentation. Sometimes, the attending physician and the consulting physician can document conflicting information, requiring additional clarification. Or there may be clinical evidence of a diagnosis being monitored, evaluated, or treated, but it has not been documented in the medical record,” says Taylor. “The CDI specialist helps resolve these discrepancies by creating written or verbal queries [and] speaking to the treating providers."

She adds that CDI specialists also check for quality and safety issues, such as hospital-acquired conditions or patient safety indicators. According to AHIMA, other responsibilities may include:

• Reviewing past patient records to spot missed diagnoses, support medical coding, or identify educational opportunities
• Creating reports that analyze trends and highlight areas for improvement
• Checking patient charts to ensure documentation processes and care standards are followed
• Educating providers on improving clinical documentation and why it’s important
• Developing CDI training programs for the clinical team

Why Is CDI Important?

According to the AAPC, CDI professionals play an integral role in the health care system by connecting clinical documentation with medical coding. Although electronic health record systems have made administrative work easier, medical providers are still responsible for accurate documentation. As a result, organizations rely on specialists to ensure document integrity.

This can have several advantages, such as:

• Improved accuracy leading to more precise reimbursement. When clinical documents reflect the specificity of a patient’s condition, the coders can more accurately translate that information, enabling better medical billing.
• Fewer improper claim submissions, claim denials, and fines. When documentation supports coded diagnoses and procedures, health care organizations are less likely to face denied claims or financial penalties due to noncompliance with payer requirements.
• Improved communication between providers. Detailed and accurate documentation helps all members of a patient’s clinical team stay informed, reducing the risk of misunderstandings or errors that could impact patient outcomes.

As Taylor explains, CDI helps health care facilities continuously improve by:

• Reminding providers to document all pertinent details about a patient visit, including treatments and diagnoses
• Helping ensure the patient's care is documented accurately
• Protecting the health care facility from potential risks and missed reimbursements

Example of Clinical Documentation Improvement

To demonstrate, Taylor uses the example of someone visiting the emergency department with signs of a serious infection.

Once the patient is admitted, an infectious disease specialist is brought in and identifies the condition as sepsis — a serious and potentially life-threatening response to infection. However, the attending physician, who oversees the patient's care during their hospital stay, never explicitly documents it in their notes.

This can pose a problem at discharge. Although the infectious disease consultant used the term sepsis, the attending physician is the one responsible for the official discharge summary. If they don’t confirm the diagnosis, it may be left out of the final record. This affects not only the accuracy of the patient's medical history but also hospital reporting and billing.

A CDI specialist steps in to fix this gap. They send a formal query to the attending physician to clarify whether sepsis should be included in the record — and whether the condition was present on admission (POA), which has important billing and care implications. In this case, even though the diagnosis wasn’t documented until later, the symptoms were present when the patient arrived, so the CDI specialist helps ensure the POA status is recorded correctly.

Important CDI Skills

According to AHIMA, the following abilities are key to CDI:

• Strong working knowledge of clinical documentation best practices
• Familiarity with medical coding systems
• Knowledge of Joint Commission standards and regulatory requirements
• Broad clinical knowledge and understanding of pathology and physiology
• Computer proficiency

In terms of soft skills, Taylor says written and verbal communication are especially important. “You have to be comfortable having a conversation with the providers,” she explains.

Education and Experience

Although many CDI professionals have clinical experience as former nurses, Taylor says others start in health information management. They may begin their careers as medical coders, which can help them gain exposure to clinical documentation and medical terminology.

CDI professionals typically hold at least a bachelor’s degree, but some employers prefer a master’s degree. In some cases, organizations require some type of CDI certification. Taylor recommends aspiring specialists consider the following:

• Certified Documentation Integrity Practitioner (CDIP)
• Certified Coding Specialist (CCS)
• Registered Health Information Administrator (RHIA)
• Certified Professional Coder (CPC)

Taylor also suggests using networking boards such as LinkedIn. Connecting with people working in CDI can help you learn about the industry and get a foot in the door.

Launch Your CDI Career at Purdue Global

Are you interested in CDI? If so, consider earning your degree at Purdue Global. Our online Bachelor of Science in Health Information Management and online Master of Science in Health Informatics can prepare you to work with clinical documentation in various health care settings.

Contact us today to request more information.

See Notes and Conditions below for important information.