What are the two main types of clinical documentation improvement (CDI) initiatives?

The two main types of clinical documentation improvement (CDI) initiatives are concurrent and retrospective reviews. Concurrent reviews involve analyzing clinical documentation while the patient is still receiving care. This allows for real-time correction of documentation to ensure that it accurately reflects the patient’s conditions and treatments during their care. It helps healthcare providers understand the importance of accurate documentation at the point of care, thereby improving the quality of records and compliance with regulatory standards as care is delivered.

Retrospective reviews, on the other hand, occur after the patient has completed their care. This type of review focuses on assessing and improving documentation practices based on the record as it stands after the care episodes, allowing for feedback and education based on observed discrepancies or deficiencies in the documentation. This analysis can lead to long-term improvements in documentation practices and overall patient care quality.

In contrast, other options such as summative and formative evaluations, or qualitative and quantitative assessments, do not specifically target the CDI initiatives in the same context. Summative assessments are typically used to evaluate education programs or outcomes rather than data documentation, while qualitative and quantitative assessments focus on types of data collected rather than the specific processes of reviewing clinical documentation.