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Clinical Documentation Improvement Audits

Concerned that your hospital’s funding doesn’t reflect the complexity of your patients? Is the quality of your documentation inhibiting accurate clinical coding? Your major problem is probably not the quality of your coders, but rather the completeness of your clinician’s documentation. You see, clinical coders must abide by a strict set of rules called the Australian Coding Standards. These standards dictate that coders cannot fill in the gaps or make assumptions from incomplete documentation. So the complexity of many patients is often lost as clinicians omit or only infer important information. Ultimately, poor clinical documentation leads to inaccurate coding and DRG assignment, leading to stressed and under-resourced hospitals. At Clinical Documentation Improvement Australia, we’ll partner with you to perform comprehensive clinical documentation audits. Distinct from coding audits, our audits are completed by doctors and senior nurses who approach the audit through an entirely different lens and produce significant results even for records that have already undergone a traditional coding audit. Our audits find documentation deficiencies across all specialties and can be conducted on paper or electronic records at public or private hospitals. 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 ensure your hospital’s funding reflects your true patient complexity contact us today. www.cdia.com.au