Clinical Documentation Improvement Australia

In Australian hospitals, it is far too common to find medical records missing documentation of the reason for admission, relevant major diagnoses, or the indications for treatments, investigations or procedures. This missing information is a major patient safety concern and can contribute to breakdowns in communication between clinicians, medication errors, and preventable patient harm. To make matters worse, this often incomplete documentation forms the basis for healthcare funding leading to stressed and under-resourced hospitals. What’s more, much of the data that leaders and policy makers rely on to make key decisions about the health of all Australians comes directly from clinical documentation. If you’re concerned about the quality of your clinical documentation, we’re here to help. At Clinical Documentation Improvement Australia (CDIA), we’ll partner with you to transform your clinical documentation culture so you can deliver safer patient care. Founded by clinicians, we draw on our team's clinical expertise to address the safety, quality and funding issues caused by poor documentation. Through our Pursuit Program, we offer a complete, sustainable solution including; clinical documentation audits, Clinical Documentation Specialist training and mentoring, hospital wide clinician to clinician education, and clinical coder medical knowledge development. Designed for public and private hospitals with either electronic or paper records, we help you create a documentation culture that reflects the clinical truth, ensures funding is accurate, and enhances the integrity of healthcare data. Delivering consistent and reliable results, we’re trusted by Australia’s leading hospital networks so you know you’re in good hands when you partner with us. If you’re ready to discover how CDIA can empower your clinicians to deliver safer patient care contact us today to find out more