This is part 2 of a 3-part blog series on the limits of traditional clinical documentation integrity (CDI) tools. Part 1 talks about the importance of clinical documentation, and part 3 explains why you should consider AI-enhanced tools.
Clinical documentation is the foundation of hospital operations, and improving it is a top priority. However, knowing exactly what obstacles you’re up against is far from simple.
Here, we explore three clinical documentation improvement challenges — and how to turn them into opportunities.
Top 3 clinical documentation improvement challenges
#1: The physician disconnect
At the heart of clinical documentation improvement challenges is a disconnect between physicians and coding teams.
Although documentation forms the basis of coding — and, ultimately, billing — this relationship is rarely emphasized in medical training, and doctors do not typically learn about coding.
On the flip side, coders are not clinicians and must rely solely on the chart. They are not allowed to make assumptions, even if they have years of experience under their belt. Coders are required to interpret medical records strictly based on the documentation provided and send time-consuming queries for clarification, creating unnecessary administrative churn on both sides.
#2. Workforce shortages
Staffing shortfalls add another layer of complexity to clinical documentation improvement.
Documentation teams are already stretched thin, and hiring more CDI specialists is not just difficult; it’s nearly impossible.
Industry standards suggest 1 CDI specialist per 1,250–1,500 admissions, but the U.S. has fewer than 6,700 credentialed professionals — far short of the 23,000+ needed. With constrained budgets and increased demand, expanding teams isn’t a viable solution.
#3. Outdated technology
Many hospitals still rely on legacy CDI systems built on rigid, rules-based logic. These platforms operate only on predefined keywords and triggers, missing clinical nuance and requiring constant manual updates.
In today’s rapidly evolving healthcare environment, legacy systems often fall short. They don’t adapt, reason, or evolve to meet the needs of modern healthcare, leaving significant gaps in both clinical accuracy and operational efficiency.
Documentation is the challenge — but also the solution
Documentation is what paints the clinical picture of each patient. Key operational, quality, and revenue metrics are based on the alignment of this picture with the consumption and quality of care provided.
Every diagnosis, treatment, and comorbidity not explicitly documented in the medical chart represents a missed opportunity for the hospital to recover the costs of providing that patient care. To stay financially solvent, hospitals must adopt scalable, adaptable solutions to improve documentation integrity now.
Activating AI-powered Clinical Documentation Integrity
Modern healthcare is driven by towering piles of data. From diagnosis to reimbursement, everything depends on asking the right questions and ensuring that the proper tests were given — and then documenting all of that quickly and confidently.
If your team is no longer able to manage the quantity and granularity of documentation, Clinical Integrity + Revenue Capture solutions can bridge the gap. Learn how today.
