7 Pillars for Effective Clinical Documentation Improvement (CDI) Resources: A Guide for Clinical Documentation Specialists

Clinical Documentation Improvement (CDI) is most effective when clinicians have resources that are practical, clear, and easy to apply. For a Clinical Documentation Specialist (CDS), the goal is not only accuracy and compliance but also to design tools that clinicians will actually use. By connecting documentation with patient safety, coding accuracy, and funding integrity, we can create resources that improve both care and system outcomes.

1. Clinical Relevance and Practical Application

Clinicians engage best with resources that reflect their daily practice. Examples should highlight common conditions, workflows, and decision-making moments.

• Use real clinical cases and vignettes

• Provide sample notes that connect with ICD-10-AM standards

• Translate coding requirements into clear clinical terms

2. Coding Accuracy and Standards

Accurate documentation underpins compliance and reliable data. A small change in wording can alter DRG assignment and funding.

• Highlight vague versus specific terminology

• Emphasise alignment with ICD-10-AM, ACHI, and ACS

• Show examples where wording changes impact outcomes

3. Clarity and Accessibility

Busy clinicians need resources that are quick and easy to use. Dense manuals will not be effective.

• Provide infographics, flowcharts, and concise summaries

• Make resources available in both digital and printable formats

4. Design and Visual Impact

The look and feel of resources influences how likely they are to be noticed. Clean design builds trust and professionalism.

• Use simple fonts, colour contrast, and clear layout

• Apply consistent branding and easy-to-read headings

5. Education and Engagement

Resources that explain why documentation matters encourage ownership and change.

• Build interactive learning such as cases and quizzes

• Encourage two-way feedback and discussion

6. Ethical and Professional Framing

Framing CDI as collaborative helps reduce defensiveness and promotes trust.

• Position CDI as patient safety and quality focused

• Keep communication professional and respectful

7. Adaptability and Sustainability

Resources must be able to evolve as coding standards and health systems change.

• Use modular guides and digital templates

• Adapt resources across specialties and settings

Developing CDI resources is about more than compliance. It is about shaping tools that clinicians value and use. By applying these seven pillars, CDS professionals can create resources that improve documentation accuracy, support coding standards, and strengthen patient safety.

"Whether you are a clinician, educator, or CDS, start by reviewing your current tools against these pillars. Small improvements in clarity, design, or clinical relevance can make a big difference in how documentation supports both care delivery and system sustainability."