Why Australian hospital executives are starting Clinical Documentation Improvement (CDI) Programs

Concerned about your hospital's clinical documentation? You’re not alone.

In Australian hospitals, it is far too common to find medical records missing documentation of:
- the reason for admission,
- relevant major diagnoses, or
- the indications for treatments, investigations or procedures.

This missing information is a major patient safety concern and can contribute to:
- breakdowns in communication between clinicians
- medication errors, and
- preventable patient harm.

Ultimately, poor clinical documentation undermines the delivery of safe patient care.

To make matters worse, this often incomplete documentation forms the basis for healthcare funding leading to stressed and under-resourced hospitals.

What’s more, much of the data that leaders and policy makers rely on to make key decisions about the health of all Australians comes directly from hospital's clinical documentation so it’s essential this information is accurate.

If you’re concerned about the quality of your clinical documentation, we’re here to help.

At Clinical Documentation Improvement Australia, we’ll partner with you to transform your clinical documentation culture so you can deliver safer patient care.

Founded by clinicians, we draw on our team's clinical expertise to address the safety, quality and funding issues caused by poor documentation.

Through our Pursuit Program, we offer a complete, sustainable solution including:
- Clinical Documentation audits,
- Clinical Documentation Specialist training and mentoring,
- Hospital wide clinician to clinician education, and
- Clinical coder medical knowledge development.

Designed for public and private hospitals with an electronic or paper record, we help you create a documentation culture that:
- reflects the clinical truth,
- ensures funding is accurate,
- and enhances the integrity of healthcare data.

Delivering consistent and reliable results, we’re trusted by Australia’s leading hospital networks so you know you’re in good hands when you partner with us.

If you’re ready to discover how CDIA can empower your clinicians to deliver safer patient care, contact us today to find out more.

CDIA: data integrity, sustainable hospitals and better patient care.

Hopefully this animation answers some of the common questions about CDI:

What Are the Benefits of Clinical Documentation Improvement (CDI)?

How can healthcare documentation be improved?

What does a CDI specialist do?

What is a documentation specialist in healthcare?

What is a CDI Professional?

How do you become a clinical documentation specialist?

What does CDI stand for in healthcare?