Clinical Documentation Improvement Process

Maxim realizes that every facility’s clinical documentation improvement (CDI) needs are different. What works for one client might not be the answer for another facility. That is why MHIS is pleased to offer a tailored CDI process that includes a series of phases, each with different objectives.

MHIS’ CDI phases include:

• Client Interface Phase: An introduction and explanation of MHIS’ CDI initiatives and objectives. MHIS will develop a proposal and contract for your facility and use diagnostic data to deliver documentation and compliance opportunity projections.
• Evaluation Phase: MHIS conducts a statistically valid chart review and interviews to evaluate the current state of CDI readiness at your facility and identify value gaps (MS-DRG documentation, POA coding, and RAC readiness) that will benefit from implementing the CDI program.
• Education Phase: MHIS provides education and training for your physician staff, facility designated leadership team, CDI specialists, HIM personnel, and other relevant individuals to facilitate two-way communication with your medical staff, resulting in documentation accuracy.
• Metrics and Process Follow-up Phase: MHIS provides on-site client-specified metrics in a dashboard format on a quarterly basis in an effort to support ongoing program sustainability. MHIS also conducts a CDI process assessment to encourage CDI progress.

We invite you to discover what makes Maxim a leader in the HIM and CDI industry. Contact us today to learn more about our comprehensive CDI services.