1) To demonstrate Clinical Documentation Improvement.
2) To learn and identify Policies and Procedures for Clinical
3) To define the Importance of physician training in Clinical
4) To apply training for nurses on clinical documentation
5) To identify the mandated standards in Saudi Arabia for CDI
and Coding compliance and national \ international Patient Safety Guidelines.
6) To learn the clinical documentation improvement auditing
7) To apply clinical documentation improvement Key
The main responsibility of all health care providers to ensure that each patient encounter within the health care system is documented in an accurate and timely manner. For a facility to develop a successful CDI program, there must be strong leadership and support from professional staff.
This course aims to improve the clinical documentation in the patient's medical records including (diagnosis, treatment, and progress notes) to standardize the documentation process and enhance clinical compliance, support for coding levels.
CDI's primary purpose is to support quality patient care and to ensure that all healthcare providers caring for patients during current or next episodes of hospitalization have access to the necessary records. It must be accurate, up-to-date, and understandable.
This will enable healthcare facilities to provide high-quality and safe care to patients by ensuring safe and effective communications between healthcare providers.
upon completing this activity, the participant will be able to: 1- Develop a good understanding of the Clinical Documentation Improvement objectives.
2-Assist the physicians and nurses in Ambulatory Care Centers in understanding the definition and importance of Clinical Documentation Improvements and the impact on patient safety and quality of care.
3-Learn and be able to apply the rules for Clinical Documentation and coding.
The certificate and CME will be granted for those who attend the complete the sessions, you will also need to fill out the final survey at the end of the course.