The College will be CLOSED on March 14 due to snow.

Online Clinical Documentation Improvement (CDI)

Labouré College’s Clinical Documentation Improvement Certificate program (CDI) is offered 100% online. The program includes four courses and can be completed in less than one year. The College’s CDI certificate is the only program in the area that prepares students for both national exams, the CDIP from AHIMA and CCDS from ACDIS, to earn the credentials of Certified Documentation Improvement Practitioner and Certified Clinical Documentation Specialist.

What is Clinical Documentation Improvement?

Each healthcare consumer has a combination of medical conditions that organizations must standardize for data comparison. One way to capture these data is by translating clinical documentation into codes such as ICD-10-CM and CPT.

With the implementation of the prospective payment system, coded data took on greater significance and became a mechanism for reimbursement, quality measure reporting, and profiling. The increased need for interpreting coded data for meaningful comparison and quality reporting has led to the expansion of the health information management professional’s role in clinical documentation improvement (CDI).

A CDI professional represents healthcare services through complete and accurate reporting of diagnoses and procedures.

Information from AHIMA read more


Who should apply to the CDI program?

Those who typically fill CDI roles include, but are not limited to, health information management professionals, nurses, physicians, and other healthcare professionals with a clinical or coding background. Key skills and competencies for those in CDI roles include:

  • Knowledge of coding concepts and guidelines and clinical terminology
  • Ability to read and analyze all information in a patient’s health record
  • Clinical knowledge (anatomy and physiology, pathophysiology, and pharmacology)
  • Ability to establish and maintain strong verbal and written communication with providers and other clinicians
  • Knowledge of healthcare regulations, including reimbursement and documentation requirements

Coders and nurses find that this is a challenging and revitalizing career modification and are able to use their skills and experience in a new, evolving field.

It is beneficial for applicants to have a familiarity with Anatomy and Physiology, Diseases, and ICD-10-CM coding. If applicants do not have this background, the HIT Chairperson will advise on an individual basis.

Request information about this program

Accreditation

Labouré College is accredited by the New England Association of Schools and Colleges.

The Commission on Institutions of Higher Education
The New England Association of Schools and Colleges
209 Burlington Road, Suite 201
Bedford, MA 01730-1433
E-mail: cihe@neasc.org

This program is awaiting NEASC/CIHE approval as a substantive change to Labouré College’s academic programs.

As a college with the distinct focus of education for practice in the health sector, we are committed to preparing individuals to deliver patient-centered care as members of an interdisciplinary team. The individual programs provide clinical education emphasizing evidence-based practice, including the latest research and clinical expertise. Quality improvement approaches and the use of information technology are important components of each program.