What does the term "clinical documentation improvement" (CDI) refer to?

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The term "clinical documentation improvement" (CDI) encompasses the efforts taken to enhance the accuracy and completeness of medical record documentation. This ensures that the patient's clinical information is recorded in a clear and precise manner, reflecting the true nature of the patient's condition and the care provided. Improved documentation not only helps in delivering better patient care by providing healthcare professionals with accurate information, but it also plays a crucial role in coding, billing, and compliance with regulations. By achieving higher accuracy and completeness, CDI initiatives ultimately lead to better reimbursement for healthcare services since medical records serve as the basis for evaluating the quality and reliability of the care provided, as well as its associated costs.

The other options do not adequately capture the core purpose of CDI. For instance, enhancing the speed of medical record creation, reducing costs associated with medical records, or increasing the volume of patient visits do not specifically address the quality of the documentation itself, which is fundamental to the objectives of CDI.

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