Clinical Documentation Improvement (CDI) programs are designed to enhance the accuracy, clarity, and usefulness of clinical records—not just for funding, but for communication, patient care, and health system performance. Despite this, some clinicians remain hard to win over. They may see CDI as bureaucratic, time-consuming, or irrelevant to their day-to-day work. And frankly, who can blame them?
All doctors—regardless of level, specialty, or seniority—are stretched thin. Whether it’s a junior doctor trying to keep up on a busy medical ward, a surgical registrar juggling operating lists and consults, or a consultant splitting time between patient care, research, and teaching, time is a scarce resource. Introducing another initiative can feel like adding to an already overflowing plate.
The key challenge for CDI programs is therefore not just implementation, but meaningful engagement—especially with clinicians who see documentation as a low-priority, administrative task that has little bearing on patient outcomes or their clinical responsibilities.
The Junior Doctor Years: Buried in Admin
When I was a junior doctor, it often felt like I spent more time completing paperwork than actually seeing patients. Between writing discharge summaries, clarifying management plans, responding to pages, and answering questions about unclear documentation, the administrative load was immense. So it’s no surprise that when CDI first came up, it was easy to see it as just one more task competing for limited time.
But that perception often stems from how CDI is introduced and communicated. If it’s framed solely as a way to improve coding or optimise hospital revenue, it’s easy to see why many doctors disengage. The real opportunity lies in reframing CDI as something that can save time, reduce interruptions, improve communication, and ultimately enhance care.
The Clinician’s Reality: Time is Everything
One of the most practical selling points of improved documentation is the reduction in avoidable disruptions. Incomplete or vague notes often generate follow-up phone calls from nursing staff or allied health teams needing to clarify plans, confirm orders, or fill in the blanks. These queries eat into clinical time and create frustration on all sides.
Worse still are the after-hours interruptions. Covering teams often have to make decisions for unfamiliar patients with scant documentation. Clearer, more consistent records mean fewer unnecessary calls, less second-guessing, and safer patient handovers.
CDI as a Time-Saver, Not a Time-Drain
A common misconception is that CDI adds extra work. In reality, good documentation reduces the need for retrospective queries weeks after discharge—queries that force clinicians to recall details from long-forgotten cases. If the clinical story is told properly the first time, there’s no need to revisit it.
Additionally, many documentation improvements are small but impactful: clarifying diagnoses, clearly stating clinical impressions, documenting complications or comorbidities, and aligning the problem list with the patient’s real clinical picture. These aren’t new tasks—they're simply part of good medicine. CDI helps clinicians express their clinical thinking more clearly, which also protects them medico-legally and enhances the value of the record for other team members.
Making the Case for Better Documentation
To engage the more resistant clinicians, CDI programs need to do more than teach—it’s about making the case in terms they care about:
Clinician-led education, peer champions, and audit-feedback cycles can be powerful tools. The most successful CDI programs create partnerships with doctors, not demands. They listen, adapt, and build trust.
Conclusion: Meeting Clinicians Where They Are
CDI isn’t just about forms or codes—it’s about telling the patient’s story accurately, clearly, and completely. If we can show clinicians that better documentation helps them, their teams, and their patients, we’re far more likely to see lasting engagement.
Ultimately, even the most sceptical doctor wants to spend less time on the phone, write fewer discharge summaries with missing information, and provide safer, more efficient care. CDI, when done well, helps them do just that.
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.