Inpatient Clinical Documentation Improvement Program Outline
Advance your career with exceptional CDI specialist training.
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Overview
Our program is divided into 12 easy-to-digest courses that cover a variety of topics, including inpatient coding, pharmacology, and health information best practices. You'll also prepare to sit for industry-recognized certification exams like the Certified Documentation Integrity Practitioner (CDIP) from the American Health Information Management Association (AHIMA) or the Certified Electronic Health Records Specialist (CEHRS) credential from the National Healthcareer Association (NHA).
Program Timeline
Our program is completely self-paced, so you have the flexibility to study as much or as little as your schedule allows—with up to 12 months of access to get certification-ready.
12 individual courses
12 months of full program access
Training Format
No rigid schedules. No unreasonable deadlines. With training that’s 100% online, you can make your way through your program at your own pace, on your own terms.
Learn from home (or anywhere)
Train online (anytime)
Support
There’s no reason to ever feel alone on your career journey. If you ever need any assistance as you make your way through your training, we’ll be here to help.
One-on-one support
Phone, chat, and email
Inpatient Clinical Documentation Improvement Program Outline
Want to set yourself apart from others with similar experience in your field? This program covers a number of topics (inpatient coding, data analysis, clinical documentation, and more) that will expand your skill set and increase your value in the industry.
Program Orientation: Clinical Documentation Improvement—Inpatient
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Initiate Clinical Documentation Improvement- Inpatient Program.
Introduction to Healthcare
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Identify health information management concepts common to allied health professionals.
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Describe characteristics of health care delivery and settings in the United States.
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Delineate career opportunities for health information management professionals.
Digital Technology
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Have a basic understanding of the internet and evaluated hardware
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Understand and be able to use various programs and apps
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Be able to explain privacy and digital security in digital technology
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Describe the fundamentals of input and output
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Have an understanding of network devices
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Use technology to help you find a career
Comprehensive Medical Terminology
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Analyze how medical terms are built using common word parts.
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Properly spell, define, and pronounce medical terms associated with each of the major body systems.
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Identify and define the word parts most frequently associated with the major body systems.
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Interpret common abbreviations used in medical terminology and cautions to remember when using them.
Law, Liability, and Ethics for Healthcare
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Describe the structure of the healthcare industry and how it relates to the medical office profession.
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Identify law and regulations related to the healthcare workplace.
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Describe how law flows from the constitution to the courtroom.
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Identify criminal acts and intentional torts.
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Recognize what makes a contract and who can contract.
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Identify medical malpractice and other lawsuits.
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Explain the characteristics, ownership, and confidentiality of the health record.
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Recognize the importance of the laws and ethics of patient confidentiality.
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Explain professional ethics and how they apply to patients.
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Recognize ethical issues surrounding the beginning of life.
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ecognize ethical issues surrounding death and dying.
Anatomy and Physiology
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Identify the structures, locations, and functions of major body systems and the organs that comprise them.
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Explain how the organs of the major body systems interact and maintain homeostasis.
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Compare various risk factors leading to high mortality and morbidity.
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Describe the components of cell structure and their functions.
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Summarize how infectious agents affect cellular growth and function.
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Define basic anatomical terms.
Health Information Management
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Explain the role of health information management in patient care documentation and medical coding and billing.
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Identify types of health records and the documentation requirements, data sources, collection tools, and potential issues associated with each type.
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Discuss the evolution of the electronic health record (EHR) and its administrative and clinical applications.
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Describe records storage and retrieval processes, including numbering and filing systems and record storage and circulation methods.
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Explain health record maintenance through the use of the master patient index and data collection, indexes, and registers.
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Identify the principles, professional practice standards, and regulations related to the use of the health record as a legal business record.
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Describe the processes and legal requirements for the release of personal health information.
Comprehensive Pharmacology
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Define basic pharmacology terminology.
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Identify U.S. drug laws and explain their importance in patient care and health services documentation.
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Differentiate among drug classifications, routes of entry, mechanisms of action, and therapeutic treatments related to specific body systems and disease conditions..
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Identify medication side effects, precautions, contraindications, and interactions.
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Identify major drug standards, legislation, legal responsibilities of the health care practitioner when dispensing medications.
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Identify the major drug classification systems and differentiate among the various types of drug names with examples.
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Evaluate the standard and online pharmacological references in use today.
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Classify the sources of drugs, examine their pharmacokinetic processes, and analyze the variables that affect drug actions and effects.
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Analyze various drug forms, routes of delivery, and the supplies and techniques necessary for safe and appropriate administration.
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Identify commonly used medications and their characteristics.
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Identify the sources, mechanism of action, and indications for specific drug therapies.
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Analyze the side effects, precautions, contraindications, and interactions for specific medications.
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Assess the factors that influence the absorption and effectiveness of drugs.
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Analyze the physiological effects of prolonged drug use and discuss the responsibilities of a health care practitioner in addressing and treating drug abuse.
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Investigate recent actions taken by the government and by manufacturers for specific drugs.
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Identify the key factors involved in considering drug therapies for older adults.
Comprehensive Electronic Health Records
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Demonstrate how patient records are used and regulated.
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Complete tasks required for scheduling patient appointments.
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Clinical information reporting.
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Apply basic coding for reimbursement claims.
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Revenue cycle and financial reporting.
Inpatient Coding
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Accurately assign and sequence ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes according to official guidelines for inpatient services.
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Identify and describe different types of hospital facilities and their documentation and coding standards.
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Differentiate MS-DRG and APC assignments.
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Describe the query process and its impact on data integrity and reimbursement.
Clinical Documentation Improvement - Inpatient
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Understand the definition and importance of the Clinical Documentation Improvements.
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Know the required clinical documentation for specific code assignments.
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Identify common areas for physician documentation improvement.
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Understand the goals of clinical documentation improvement programs.
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Describe the role of the CDI professional in CDI programs.
Program Completion: Clinical Documentation Improvement—Inpatient
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Prepare to take next steps for program completion.
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Inpatient CDI Certifications
CareerStep’s online Inpatient Clinical Documentation Improvement training covers the knowledge and skills you need to successfully sit for industry-recognized certification. We want to support our learners in securing the certification that fits based on your career goals and current job requirements. Your training includes up to two different exam vouchers for the certifications listed below, relevant to your training – a significant value add of several hundred dollars.
Certified Documentation Integrity Practitioner (CDIP)
The CDIP credential demonstrates expertise in clinical documentation within patient health records - certified by the American Health Information Management Association (AHIMA). Note: While no specific experience is required to sit for the certification exam, this is a high-level certification, so we recommend Learners have at least 2 years of experience in clinical documentation improvement.
Certified Electronic Health Records Specialist (CEHRS)
Demonstrate you have the Electronic Health Record skills employers seek with the CEHRS from the National Healthcareer Association.
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