How Do You Distinguish Clinical Documentation?

AHIMA August 2, 2021
Cheryl Ericson, MSN, RN, CDIP, CCDS; Rachel L Pratt, RHIA, CDIP, CCS; and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP

The introduction of technology into the healthcare industry has disrupted the health information (HI) and clinical documentation integrity (CDI) profession more than could have been anticipated. Yes, documents are more legible, but the integrity of documents is increasingly questionable because it is difficult for those translating the health record into reportable healthcare data to distinguish “clinical documentation” from other text within the health record.

For the purpose of this article, we will define “clinical documentation” as an intentional diagnostic statement by a practitioner. We base this definition on the ICD-10-CM Official Guidelines for Coding and Reporting, which state, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists,” as well as the requirement...

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