Physician Documentation

As part of an ongoing effort to improve quality and safety for our patients, Inova supports our physicians with information and programs on medical record documentation. Improving documentation leads to better communication among caregivers as well as improved measurement of quality outcomes based on severity of illness and risk of mortality. Clinical Documentation Improvement Program In 2012, Inova implemented a Clinical Documentation Improvement (CDI) program to support physicians with their documentation of diagnoses, Present on Admission status and procedures for acute inpatient care. CDI positions Inova and its physicians to succeed in the future environment where quality will be the primary driver of value-based purchasing of healthcare services. Overview Hospital-Based Documentation Support for ICD-10 Epic Documentation Initiatives Templates and References Inova EPAC Approves Documentation Guidelines