Clinical Documentation Improvement

Clinical documentation improvement has made such considerable growth in the medical field that many health professionals are being trained in documentation coding as well. Clinical or medical documentation is the process of keeping account of everything about the treatment procedure of the patient. All information like the name of the patient, date of birth, medical history, the assessment of the problem, the treatment given for the problem identified, the response of the patient, and the subsequent outcomes are recorded in a precise and concise manner. Medical documentation is a type of written communication between the patient, his clinicians, and between other health care professionals.

In a clinical documentation improvement program, the data once stored cannot be deleted or changed in any way. Only factual and correct data is to be entered. This thus makes the documentation reliable as well as verifiable. Earlier, medical documentation was hand written by nurses, clinicians and everyone else who was involved in the treatment of the patient. Care was taken to make sure that the information was legible. A particular type of ink was supposed to be used. No corrective ink or erasers were allowed. This type of documentation had some hindrances, which made people look for other solutions.

With the improvements in the field of medical technology, many types of software have been programmed and designed for the purpose of documentation. These software come in various levels of complexity. Some can be directly used by an individual whereas some others need dedicated clinical documentation improvement professionals to do the job. Many companies offer different types of software. You can learn about these software and their use by going through a free tutorial supplied along with the software when you purchase it. Documentation like these, provide for a quality assurance mechanism in evaluating professional practice of medicine.


One can learn about clinical documentation improvement programs through many different sources. There are books that give you tips on how to make effective medical documentation. Some books also give you a systematic procedure on how to make accurate documentation. You can also browse online for help on this. The clinical documentation source book also helps you greatly in setting up your own clinical documentation. Alternatively, you can refer to any previously made clinical documentation of any health organization.

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