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Skilled Nursing Facility (SNF/NF) Clinical Documentation Improvement (CDI) Tip Sheets

Author: AHIMA Long Term Care CDI Workgroup

Source: AHIMA Task Force

Publication Date: February 2017

These tips focus on the language and/or wording that will garner greater details and specificity of the coded data for a given diagnosis, condition, and disease. In addition to the focus on coded data, these tips also include information to reflect quality care, frequency of documentation requirements, and documentation sources. These tips are meant to provide guidance in recognizing gaps in the clinical documentation.

American Health Information Management Association Standards of Ethical Coding [2016 version]

Author: AHIMA House of Delegates

Source: AHIMA

Publication Date: December 2016

The AHIMA Standards of Ethical Coding are intended to assist and guide coding professionals whether credentialed or not; including but not limited to coding staff, coding auditors, coding educators, clinical documentation improvement (CDI) professionals, and managers responsible for decision-making processes and operations as well as HIM/coding students. The standards outline expectations for making ethical decisions in the workplace and demonstrate coding professionals' commitment to integrity during the coding process, regardless of the purpose for which the codes are being reported.

Assessing and Improving EHR Data Quality: Model for Implementing an EHR Documentation Improvement Process

Author: AHIMA e-HIM Work Group on Assessing and Improving Healthcare Data Quality in the EHR

Source: Journal of AHIMA

Publication Date: March 2007


Improving data quality in an electronic healthcare environment requires a greater focus on standardized documentation procedures. With an EHR, the need to evaluate and improve healthcare data quality through concurrent assessment, data collection monitoring, and ongoing process improvement requ....

Electronic Signature, Attestation, and Authorship. Appendix A: HL7 EHR-System Records Management and Evidentiary Support (RM-ES) Functional Profile Standard Excerpt (2009 update)

Author: AHIMA e-HIM Work Group: Best Practices for Electronic Signature and Attestation

Source: AHIMA practice brief attachment

Publication Date: November 2009


The records management and evidentiary support functional profile standard is a subset of functions and conformance criteria from the HL7 EHR-S Functional Model standard. The standard was created specifically to address requirements and criteria for basic record management functionality in EHR....

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