Over the past several months, I’ve noticed a growing trend on LinkedIn: a surge of posts and commentary about Clinical Documentation Improvement (CDI). People are generously sharing their tips, interpretations of coding standards, and advice for improving DRG assignment. At first glance, this might seem like a dream come true for those of us who’ve been in the CDI space for a while. Enthusiasm, engagement, and interest are all things we want more of in this field.
After working in CDI for over a decade, it's refreshing to see CDI frequently being discussed on these platforms however I’m growing increasingly concerned about the direction some of this content is taking. Many of these posts, while well-intentioned, lack a strong foundation in the principles and standards that underpin our work. Some are clearly generated or assisted by AI tools like ChatGPT, which can be incredibly helpful when used correctly, but also risky when relied upon uncritically. Just because a post appears confident doesn’t mean it’s correct. And in a field where accuracy matters deeply, this is not a minor issue.
At its core, CDI is about one thing: capturing the clinical truth. It’s not just about DRGs or revenue, though that’s a part of it. It’s about ensuring that the patient’s story is accurately, clearly, and compliantly documented in the medical record. This documentation then supports coding, which drives data, which in turn informs decisions across healthcare.
The foundation of good CDI rests on three core principles:
It’s important to recognise that clearly documenting a diagnosis doesn’t always lead to a higher complexity DRG or increased funding. And that’s OK. The real value is in the improved communication across the healthcare team, a more complete picture of the patient’s journey, and a health record that can stand up to scrutiny.
What concerns me most is that, with so many posts circulating - some containing inaccuracies or oversimplifications - there’s a real risk of misinformation spreading, especially among those newer to the profession. In CDI, perception can carry weight. When someone with a large following shares advice or insight, others assume it’s correct. If it isn’t, we’re unintentionally diluting the profession with flawed understanding.
We must approach this surge in content with a mix of encouragement and responsibility.
Encouragement - because knowledge-sharing is powerful. The more we talk about CDI, the better we can collectively grow.
Responsibility - because we owe it to our colleagues - and to patients - to ensure the information we share is grounded in standards, real-world experience, and the pursuit of clinical truth.
So if you are creating content in the CDI space - whether you're a seasoned expert or just getting started - keep sharing. But please also take the time to fact-check, reference your standards, and where possible, collaborate with experienced CDSs, coders or HIM professionals to ensure accuracy.
As we continue to discuss CDI and its impact, it’s crucial that we acknowledge the significant burden clinicians are already under. In many ways, the message being conveyed by some of the recent posts - about the need for more documentation - may unintentionally add pressure. The reality is that clinicians are already overwhelmed with their workload, and the last thing we want to do is give the impression that more documentation is required. It’s not about asking clinicians to document more, but rather to ensure that there is a clear, accurate link between diagnoses and treatments. The goal should be clarity and precision, not volume. By focusing on this, we can alleviate the burden on clinicians while improving the quality of documentation that truly reflects the patient’s journey and ensures the right care is provided. This approach will benefit everyone: clinicians, patients, and the healthcare system as a whole.
Together, we can build a CDI community that is both passionate and precise - one that strengthens understanding rather than diluting it.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact community@cdia.com.au to learn more.