Clinical Documentation Improvement (CDI) specialists are responsible for improving the overall integrity of medical records documentation. Their responsibilities can vary based on an individual's specific job, company, or industry. Here are some general clinical documentation improvement specialist responsibilities.

CDI includes a review of disease process, diagnostic findings, and what documentation might be missing. A CDI specialist often has both clinical and medical coding backgrounds. Bridging the gap between clinical documentation and accurate coding drives CDI programs.

While reports from laboratory tests, diagnostic tests, and consultations with specialists may also be housed in a patient’s medical record, “clinical documentation” in the context of CDI generally refers to the entries made by a provider.

While CDI may have gotten its start in the inpatient environment, outpatient providers have recognized the benefit and sta...