As a Clinical Documentation Specialist with 13 years experience in CDI, and as the Director of Clinical Documentation Improvement Australia (CDIA), I have had the privilege of watching CDI mature across multiple health systems. More recently, I’ve been closely following the conversations, articles, and LinkedIn posts emerging from the Kingdom of Saudi Arabia. There is no doubt that the Kingdom is making strong progress in CDI maturity, capability building, and physician engagement. However, there is one significant and consistent gap that continues to concern me.
The overwhelming majority of CDI content coming out of Saudi Arabia is focused almost exclusively on physician documentation.
While physician documentation is undeniably critical, an over-reliance on physician only education fundamentally misses the true purpose of clinical documentation improvement. The primary goal of CDI should never be funding, DRGs, or coding accuracy alone. At its core, CDI exists to support high-quality, safe patient care through clear, complete, and consistent clinical communication. When documentation accurately reflects the patient’s clinical story, coding improves naturally, DRGs align appropriately, and funding follows as a downstream outcome, not the starting point.
When CDI efforts focus solely on educating physicians “how to document for coding,” an entire group of clinicians is inadvertently excluded, even though their documentation directly contributes to the patient record and, in many cases, can be coded from directly.
This is particularly important in the Saudi context. The Australian Coding Standards, which have been adopted in the Kingdom, clearly allow documentation from clinicians working within their scope of practice and specialty to be coded directly. This is not a theoretical concept, it is a practical, operational reality that CDI programs in Saudi Arabia must actively acknowledge.
ACS 0010 states:"Generally, documentation by medical and surgical clinicians is the primary source for classification purposes. However, documentation by other clinicians may also be used to inform code assignment or add specificity where the documentation is appropriate to the clinician's scope of practice".
This means that documentation authored by non-physician clinicians can directly impact coded data, clinical complexity, and the accuracy of the patient episode.
These clinicians include:
Malnutrition documented by a dietician
Poor diabetic control documented by a diabetes educator
Pressure injuries documented by a registered nurse or clinical nurse wound specialist
Postpartum haemorrhage documented by a midwife
Dysphagia documented by a speech pathologist
Lactation disorder documented by a lactation consultant
Excluding these clinicians from CDI education is not only a missed opportunity, it creates risk. If these professionals are not supported to document clearly, consistently, and within clinical standards, the record becomes fragmented. The result is not just coding inaccuracy, but weakened clinical communication across the multidisciplinary team.
General bedside nurses deserve specific mention. While their documentation is not coded directly under Australian Coding Standards, nurses are at the bedside 24/7. They observe clinical changes in real time. Their notes often contain the earliest indicators of deterioration, complications, or evolving diagnoses. Coders frequently identify clinical cues in nursing notes and then search the record for corroboration from physicians or allied health clinicians. Without strong nursing documentation, those cues may be lost entirely. As explored in the article From Bedside to CDI: Why Nursing Documentation Matters, nursing notes often provide the clinical context and continuity that allow emerging diagnoses and patient complexity to be recognised across the medical record.
This reinforces a fundamental truth that experienced CDS professionals understand well: the medical record is a collective narrative. It does not belong to one profession alone.
If CDI programs in Saudi Arabia are to truly support patient safety, quality outcomes, and sustainable funding models under Vision 2030, education must extend beyond physicians. Every clinician involved in patient care should understand what constitutes high-quality clinical documentation, why it matters, and how their role contributes to the integrity of the record.
Physician advisors and physician champions play a critical role in this cultural shift. By advocating for inclusive, multidisciplinary documentation education, they can help move CDI away from a narrow, coding-centric model toward one that genuinely reflects clinical reality.
The future of CDI in the Kingdom is promising, but it will only reach its full potential when every clinician’s voice in the medical record is recognised, valued, and developed.