Clinical documentation is utilized throughout the healthcare field to provide accurate recording of patient care. Clinical documentation improvement (CDI) is a growing sector within the health information management industry (HIM), which serves to validate healthcare that is provided and to optimize medical claims processing. As the medical landscape shifts and becomes more specialized, and more detailed levels of documentation and medical coding are required, clinical documentation specialist (CDS) are essential for promoting quality documentation and medical record integrity.
Developed in conjunction with professionals from NYU Langone Medical Center, the Advanced Diploma in Clinical Documentation Improvement for Medical Professionals is a one-semester, blended program that offers students with a clinical background the opportunity to develop the critical skills required of CDI specialists, including knowledge of coding guidelines and principles. At the completion of this advanced diploma students are able to understand the role of CDS and the function of CDI programs, understand query concepts and formulate physician queries, and facilitate improvement in the overall quality of documentation.
Note: Because of the specialized nature of this program, students applying for admission must hold an RN license with greater than two years of clinical experience or an MD or DO license with greater than two years of clinical experience. Students with a foreign medical degree and two years of experience in a clinical setting may also apply.
Students will be prepared to develop provider queries by responding to case studies. Based upon the case examples, students will present target documentation needs for provider education, demonstrating knowledge of CDI and the ability to communicate with providers, executive leaders, and peers.
- Knowledge of coding concepts and principles
- Comprehension of medical terminology and clinical knowledge (anatomy and physiology, pathophysiology and pharmacology)
- Ability to read and analyze data in a patient health record
- Aptitude in establishing and maintaining strong verbal communications with clinicians and providers
- Clinical Documentation Improvement Specialist
- Clinical Documentation Improvement Coordinator
You'll Walk Away With
- An understanding of the role of the CDS and the function of CDI programs in hospitals
- Proficiency in applying ICD-10 coding
- The ability to apply clinical knowledge to analyze and to interpret medical records
- An understanding of query concepts and the ability to formulate physician queries
- The skills to facilitate improvement in the overall quality of documentation