Clinical Documentation Improvement Specialist Program
Program Overview
The Clinical Documentation Improvement Specialist Program is emerging in Canada as organizations identify the need to better reflect the complexity, acuity and resources used for patients, thus impacting quality measures, data, development of best standards, and funding.
This comprehensive, online program will provide an advanced level of competency for those working in, or wishing to work in, clinical documentation improvement positions.
Course Outline
This program has 12 modules. The time it takes to complete this program varies based on a student’s previous clinical and/or coding experience and experience in clinical documentation improvement as well as their learning style. Individuals will have a maximum of 12 months to complete the program.
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Module 1
Describes what clinical documentation improvement is, the importance and the challenges, medical record review and requirements, stages of a CDI program and the role of a CDI specialist.
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Module 2
Focuses on coding, classification, general coding standards, and common guidelines.
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Module 3-11
Provides a clinical review of common disorders and diseases, various coding standards and how they pertain to each system and a review of query indicators and opportunities. Specific guidelines and medical record documentation requirements are reviewed to support appropriate code assignment.
- Module 3 – Respiratory System
- Module 4 – Circulatory System
- Module 5 – Nervous System
- Module 6 – Digestive System
- Module 7 – Hepatobiliary System
- Module 8 – Endocrine System
- Module 9 – Renal System
- Module 10 – Infectious Diseases
- Module 11 – Musculoskeletal System
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Module 12
Focuses on factors affecting or affected by code assignment, how to select charts for review, reviewing a chart, the query process and how to analyze the data.
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Tuition Cost
$3900.00 + applicable tax (once registration is complete, there are no refunds)
Use the form below to apply for enrollment. Once admission eligibility has been confirmed, you will be contacted for providing payment, following which you will be provided access to the course.
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CPE Credits
CHIMA’s professional members who enrol in this program will earn 30 CPE credits upon completion.
Admission Requirements
The following requirements are mandatory for admission into the CDI program.
Applicants must be one of the following:
- Nurse or physician with a minimum of 3-5 years of experience working in a health care setting; or
- Certified Health Information Management (CHIM) professional with a minimum of 3-5 years of experience in classification and coding or decision support; or
- Regulated health professionals who have 3-5 years of extensive clinical experience and have completed course work in anatomy and physiology, medical terminology, and clinical pathology.
“I felt the content was well designed. The review of health records and requirements was well done and relevant even to those of us who have been HIMs for many years. The CDI component was very informative and helps those of us beginning CDI programs with some pertinent information for successfully launching our CDI initiatives. Well done!”
Karelyn Van Wynen, Manager Health Records and Patient Registration, Bluewater Health
Frequently Asked Questions
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Who would be best suited to enroll in this program?
This program is for HIM professionals, nurses, physicians, and regulated health professionals who have a strong foundation in anatomy, physiology, pathophysiology, and pharmacology. These individuals are able to read and analyze all the information in a medical record and identify any gaps. As the goal of CDI is to improve the accuracy and completeness of clinical documentation, these groupings of individuals are best equipped to assess the clinical evidence and carryout the necessary follow up, including querying and educating physicians.
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If I am eligible to enroll in this program, can I begin learning at any time?
Yes. This is an online program delivered through the 3MSM Health Care Academy learning portal and you can begin at any time.
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Why is clinical documentation improvement important?
Now more than ever, a strong, highly respected clinical documentation improvement program can make a difference in achieving the goals of improving quality of care, improving case mix, and appropriate utilization of resources through quality information. In response to industry demand, 3M Canada, in partnership with CHIMA, developed the program to lead to advanced certification in CDI.
- I have significant experience but I do not meet the admission requirements. Is there any other way to enter this program?
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Why would nurses be suitable for the clinical documentation improvement program?
Physician documentation is often received in clinical terminology, not always listing the diagnostic equivalent. Highly-skilled nurses have the in-depth knowledge of disease processes, symptomology and appropriate treatment, as they have a background in the body systems, differential diagnoses, and corresponding common co-morbidities/complications associated with various diagnoses.
Many organizations have transitioned nurses in their respective organizations into this role as they have the knowledge and skills to “connect the dots” of signs and symptoms to lab/test results and then the treatment, thus identifying opportunities for diagnosis and/or specificity what was not documented by the physician.
Depending on the facility, the nurse continues to be a part of their respective unions as the position is just simply a transition to a new role, perhaps within their own organization. Often these positions provide an opportunity for nursing staff who have had injuries and who are unable to work at the bedside any longer. The roles of a CDI specialist include directing and managing the daily operations and processes of the program, such as:
- Conduct in-depth chart analysis to review the quality of the clinical documentation and identify any gaps and opportunities for improvement.
- Act as a liaison between the coding team and physicians.
- Gather data and analyze performance metrics to focus CDI efforts.
- Develop tools, and resources to support both coding staff and clinicians.
- Provide training materials and deliver educational sessions.
- Implement solutions to leverage technology and electronic health record.
The position brings an exciting opportunity for nurses to bring their skill and expertise to the forefront and be a part of improving overall healthcare in Canada.
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Is the Clinical Documentation Improvement Specialist Program available in both English and French?
No. At this time course material and correspondence are available in English only.
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If I have successfully completed the course and want to become certified, what is the process?
The examination and CCDIS certification process is managed by the Canadian College of Health Information Management (CCHIM), and CHIMA membership and associated fees may be required to obtain and maintain CCDIS certification. More details may be found here (English only).
Learn more or apply for course enrolment.
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