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Outpatient Clinical Documentation
Improvement (CDI): An Introduction
WHIT E PAPER
Summary: In order to facilitate the growth of outpatient CDI, the ACDI Advisory Board
has written the following white
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What is outpatient clinical documentation?
Outpatient clinical documentation is a record of medical services provided to a patient during an outpatient visit.
Who is required to file outpatient clinical documentation?
Healthcare providers, such as doctors, nurses, and other medical professionals, are required to file outpatient clinical documentation.
How to fill out outpatient clinical documentation?
Outpatient clinical documentation is filled out by documenting the details of the patient's visit, including symptoms, diagnosis, treatment provided, and follow-up care.
What is the purpose of outpatient clinical documentation?
The purpose of outpatient clinical documentation is to track and communicate the care provided to a patient, ensure continuity of care, and facilitate billing and reimbursement processes.
What information must be reported on outpatient clinical documentation?
Information that must be reported on outpatient clinical documentation includes patient demographics, medical history, examination findings, treatment plan, medications prescribed, and follow-up instructions.
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