Title: Syllabus
Course: HIM 3620 - TAACCCT Grant

INSTRUCTOR: Update/change the following information as needed and delete these highlighted notes.

Principles of Clinical Documentation Improvement

Course Description

Clinical documentation is the foundation of every patient health record.  This courses addresses the fundamentals of clinical documentation-assessing the current quality of health record documentation, development of a CDI program and process.  How clinical documentation improvement impacts the revenue cycle of a healthcare organization will be reviewed.

Instructor

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Text

Hess, P.C. (2015) Clinical Documentation Improvement.  Chicago, IL:  AHIMA. ISBN:  978-1-58426-502-3

Course Schedule (hint: week=module)

Week 1          Fundamentals of Clinical Documentation; Why is it important?

Week 2          Types of Clinical Documentation.

Week 3          The Translation of Clinical Documentation in Coded Data

Week 4          ICD-10-CM/PCS in Clinical Documentation Improvement

Week 5          Assessing Clinical Documentation

Week 6          Physician Query Process

Week  7         Midterm

Week 8          CDI Program Data

Week 9          Ensuring Compliance

Week 10        CDI Best Practicies; Appeal Writing

Week 11        CDI Technology

Week 12        CDI in all Health Care Settings

Week 13        Critical Thinking in CDI

Week 14        Final Project Case Studies

Course Objectives

Upon completion of this course, the student will be able to:

- Define and understand the components of CDI
- Identify key components of a CDI program
- Write multiple types of Queries for CDI programs.
- Develop knowledge and skills required to implement a new CDI program or improve a current CDI program
- Understand the query process
- Write multiple types of Queries for CDI programs.
- Define and explain the significance of CDI, coding, and providers within the CDI process
- Understand the best ways to train staff and physicians
- Know how to develop a process to document and track queries
- Ensure compliance with all laws and regulations related to documentation and reimbursement
- Ensure a positive working relationship between providers and the CDI team
- Track CDI metrics and understand the results/measurement and analysis
- Understand Critical thinking and important features needed in CDI role

Grading Scale

Percentage |  | Grade
94-100% | = | A
90-93% | = | A-
87-89% | = | B+
83-86% | = | B
80-82% | = | B-
77-79% | = | C+
73-76% | = | C
70-72% | = | C-
67-69% | = | D+
63-66% | = | D
60-62% | = | D-
Below 60% | = | E

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