In the final session of CDI 2025, Dr Danielle Corish and Dr Sophie De’Ambrosis invited
attendees to view clinical documentation improvement through the lens of a junior doctor. This workshop explored the common challenges faced when working with clinicians and highlighted how practical, human-centred strategies can foster stronger engagement and lead to meaningful improvements in clinical documentation. The session drew on the diverse perspectives of participants— including Clinical Documentation Specialists, Clinical Coders, Health Information Managers, Nurses, Allied Health professionals and Doctors —who shared valuable, firsthand insights from their own experiences.
1. Cultural Barriers
Quote: “It’s the other surgical team’s way of documenting that’s causing the documentation issues, and I don’t want my complication rate to increase!”
- Promote a holistic approach with shared accountability.
- Reframe documentation as part of team-based patient care.
- Use education and open discussion to shift mindset.
2. The Coding Conundrum
Quote: “Why can’t the coders just code from my plans – it’s obvious!”
- Explain coder limitations: they can’t code from plans—only from linked diagnoses.
- Coders aren’t medically trained—educate on different understanding levels.
- Encourage collaboration: ask peers and clarify uncertainties.
- Reinforce benefits of good documentation for coding, patient safety, and data integrity.
- Address matters such as illegible writing or vague plans.
3. Inadequate Education
Quote: “I’m confused about these ‘CDI protocols, no one explained them clearly and I feel lost.”
- Clarify what CDI is and isn’t—address confusion directly.
- Provide targeted education sessions.
- Illustrate the impact on patient care and system outcomes.
- Establish ongoing feedback loops and build rapport over time.
4. Request for Valuable Codes
Quote: “Why don’t you just give us a list of the codes with big revenue?”
- Reframe focus: we’re seeking the clinical truth, not "gaming" the system.
- Explain that good documentation = accurate data = fair funding.
- Be tactful—sometimes this question stems from fatigue or frustration.
- Reinforce documentation’s role in quality, safety, and legal accountability.
- Offer feedback and stay open to dialogue—pick the right moment if tensions
are high
5. Burnout and Overwork
Quote: “I don’t have time for this, I’m already too busy!
- Acknowledge the reality of clinician workload.
- Show empathy and avoid taking resistance personally.
- Offer workarounds, small changes, or supportive tools.
- Focus on what’s achievable, not perfection.
6. The Junior Doctor’s Dilemma
Quote: “My consultant never explains what the diagnosis is, and I’m too intimidated to ask.”
- Consider asking a nurse or another member of the team who you feel more
comfortable with.
- Consider certain ways of phrasing your question: “Just for my own learning…”or “Can I clarify the treatment plan?” or “Can I document a suspected condition or impression?”
- Encourage confidence in junior staff: it’s okay to ask questions.
- Use clinical education and peer discussion to build skills.
- Normalise documenting clinical impressions—they’re valid and useful.
7. Negative Perception of CDI
Quote: “The CDI team just seems to be looking for mistakes. I don’t feel supported.”
- Acknowledge the concern.
- Position CDI as a complementary, supportive role.
- Build relationships with positive reinforcement and humour (e.g. chocolate).
- Give feedback not just on errors, but also on what was done well.
8. Fragmented Communication
Quote: “I thought we were supposed to be on the same page, but I keep getting conflicting instructions from different people.”
- Validate their experience and clarify the confusion.
- Share accurate information with all stakeholders.
- Push for consistency, including policies and shared education.
- Ensure senior leadership communicates a clear standard.
9. Competing Priorities
Quote: “I need to prioritise my patients over paperwork. Documentation doesn’t save lives, right?”
- Reframe documentation as a safety tool, not a distraction.
- Explain how clinical notes can reduce clinical risk (e.g., clarifying medications, handover).
- Highlight how good documentation saves time in the long run by reducing queries.
10. Lack of Feedback Mechanisms
Quote: “I’ve changed my documentation, but I’ve never heard anything back. It’s hard to know if I’m doing it right!”
- Provide ongoing, specific feedback, not just audits.
- Celebrate small wins and acknowledge improvement.
- Use data to show progress.
- Again, never forget the chocolate!
11. Resistance to Change
Quote: “We’ve always done it this way, I don’t see why we need to change now!”
- Share data and benchmarks to show why change is needed.
- Offer alternatives that make their job easier.
- Highlight fewer interruptions as a benefit of clear documentation.
12. Perceived Lack of Clinical Relevance
Quote: “I just want to focus on taking care of my patients and not wasting time on more documentation."
- Reinforce how documentation supports clinical care.
- Explain the risks of inadequate notes.
- Promote the idea that documenting well now means less interruptions and reduced risk
13. Insufficient Resources
Quote: “With so few staff members, it’s impossible to keep up with documentation. I feel like I’m drowning.”
- Be flexible and respectful of their time.
- Use tools (e.g. templates) wisely.
- Investigate documentation processes and suggest improvements.
- Reassure: CDI isn’t about more notes, just more effective notes.
- Acknowledge the human side of burnout and push for smarter, not harder, solutions
Conclusion
This workshop highlighted the importance of understanding documentation through the eyes of junior doctors—their pressures, frustrations, and priorities. The path to sustainable CDI lies in empathetic communication, tailored education, and a culture of support over criticism. When documentation is aligned with clinical purpose and identity, it becomes not just a task, but a powerful tool for safe, high-quality care.