Syllabus - Clinical Documentation Improvement

 Clinical Documentation Improvement (CDI)

Duration: 3 weeks
Credit Equivalent: 1.5 credits

Course Description

This course teaches how better documentation improves patient care, data quality, research, and reporting, especially in low-resource and hybrid (paper + digital) settings.

Learning Objectives

By the end of this course, learners will be able to:

1. Explain why high-quality documentation is critical to patient safety
2. Identify documentation gaps affecting nursing, case management, and research
3. Apply CDI principles in paper-based and electronic systems
4. Support accurate coding, reporting, and research using better documentation
5. Collaborate across disciplines to improve clinical records

Weekly Topics

Week 1: Foundations of Clinical Documentation

• What is clinical documentation?
• CDI in paper vs electronic systems
• Common documentation problems in LMICs
• Simple documentation audits
• Documentation across the care continuum

Week 2: Clinical Documentation Improvement Across Roles

• Nursing notes and patient monitoring
• Care plans and progress notes
• Case management documentation:

Week 3: CDI for Coding, Reporting and CDS & AI

• How documentation supports ICD coding (conceptual)
• Research data quality and case identification
• Alerts, reports, secondary data use
• Cancer registries and outcome tracking
• Using basic rules (CDS logic) to flag gaps

Assessments

• Discussion (40%)
• CDI improvement proposal (40%)
• Quiz (20%)

Discussion Grading Rubric