An Opportunity to Increase Awareness

Doctor Engagement with CDI: An Opportunity to Increase Awareness

Despite the critical role that clinical documentation plays in healthcare delivery and hospital financial sustainability, doctor engagement with Clinical Documentation Improvement initiatives remains strikingly low across hospitals. This disengagement is not due to disinterest or neglect, but rather a pervasive lack of awareness and education surrounding the importance of documentation. Many doctors simply don’t realise the downstream effects of their documentation—or lack thereof—on hospital operations, resourcing, and patient care.

Reflecting on my own experience as a medical student and junior doctor, I was never formally taught how to document properly. Writing ward round notes, discharge summaries, and admission clerking was something I picked up purely by observing those around me. There was no structured teaching, no formal feedback, and no emphasis on what constituted good documentation. I also had no idea how hospitals were funded, or that the quality of my notes could directly impact hospital resources and patient care. It wasn’t until later in my career that I began to understand how critical clinical documentation is—not just for communication, but for coding, funding, and the broader functioning of the health system.

This lack of structured education—both in how to document and in understanding the link between documentation and hospital financial sustainbility—is not unique to my experience. Many junior doctors and students face the same challenges, learning documentation by observation without ever being formally taught the broader implications. As a result, a self-perpetuating cycle of poor documentation habits persists. Without formal training or an understanding of the broader implications, doctors are left disengaged from CDI efforts and unaware of how their documentation contributes to the hospital's financial health and overall service delivery.

Lack of Awareness of Hospital Funding and CDI

Doctors enter the workforce with a strong clinical foundation but often little to no knowledge of the financial and administrative aspects of healthcare. Activity-Based Funding (ABF) relies heavily on accurate clinical documentation to determine the complexity of cases treated and the resources required. However, this critical link between documentation and hospital funding is rarely, if ever, explicitly taught in medical school or during postgraduate training. As a result, doctors often do not realise that their documentation directly affects hospital revenue and resourcing, ultimately impacting patient care and service availability.

Moreover, the significance of CDI in ensuring appropriate coding and reimbursement is largely unrecognised by doctors. The lack of emphasis on CDI in medical education means that doctors often view documentation as a bureaucratic task rather than an essential component of hospital operations. Without a clear understanding of how precise and thorough documentation translates to better funding, resource allocation, and even job security, doctors remain disengaged from CDI efforts.

The Absence of Formal Training in Clinical Documentation

Another major contributor to poor doctor engagement with CDI is the absence of formal training in clinical documentation. Unlike procedural skills or diagnostic acumen, documentation is not systematically taught during medical education or training. Instead, doctors learn to document primarily through observation, imitating their senior colleagues without a structured framework or formal feedback.

Ward round notes, discharge summaries, and consultation notes are essential medical records, yet doctors often develop their documentation skills through trial and error. This lack of formal instruction means that poor documentation practices are passed down from one generation of doctors to the next, creating a perpetual cycle of incomplete, unclear, and insufficient records. This has significant consequences, including:

• Inaccurate Reflection of Patient Complexity: Poor documentation often underrepresents the severity of illness and comorbidities, leading to suboptimal coding and reduced hospital funding.
• Compromised Continuity of Care: Poorly written notes hinder communication between healthcare providers, potentially impacting patient safety and outcomes.
  
  

The Domino Effect of Poor Documentation

Because documentation skills are primarily acquired through observation, a culture of subpar documentation perpetuates itself within hospitals. Junior doctors learn from seniors who were never formally trained, and they, in turn, pass on the same habits to future generations. This creates a domino effect, where the cycle of poor documentation continues indefinitely. Without structured interventions, the system remains self-perpetuating, making it difficult to achieve meaningful improvements in CDI.

Addressing the Problem: Potential Solutions for Improving Doctor Awareness

To improve doctor engagement and awareness of CDI in our hospitals, a shift in medical education and hospital training is necessary. Possible solutions include:

• Incorporating CDI Education into Medical Curricula
  • Medical schools should introduce training on hospital funding mechanisms and the impact of clinical documentation.
  • Specialty training programs should include structured lessons on effective documentation techniques.

• Providing Formal Documentation Training in Hospitals and Enhancing Awareness through CDI Programs
  • Clinical Documentation Specialists (CDSs) should regularly engage with medical staff of all levels through both formal and informal education sessions that cover documentation best practices.
  • Senior doctors should be trained to lead by example and provide constructive feedback on junior doctors’ documentation.
  • CDSs should provide individualised, positive feedback to doctors when improvements are observed, reinforcing good habits and encouraging continued progress.
  • When necessary, CDSs should also inform doctors if their documentation significantly deviates from peer benchmarks, using data-driven comparisons to highlight outliers in a constructive manner.
    
    

Final Thoughts

The lack of doctor engagement with CDI in hospitals is largely rooted in a fundamental gap in awareness and education. Most doctors are never taught how hospitals are funded or why documentation is crucial for financial and operational efficiency. Furthermore, the absence of formal training in clinical documentation perpetuates poor documentation practices, creating a self-sustaining cycle of inadequate records. Addressing this issue requires systemic changes in medical education, hospital training, and CDI awareness initiatives. By investing in structured documentation training and fostering a culture of awareness, hospitals can improve CDI engagement, optimise funding, and enhance overall patient care.

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