groupPatricia Hay, Kathy Wilton, Jennifer Barker, Julie Mortley, Megan Cumerlato

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When clinical documentation improvement (CDI) was first introduced in the United States (US), it emerged within the policy climate of the Bush administration, with a major focus on increasing the effectiveness of hospital care and reducing the cost of the healthcare system. The Deficit Reduction Act 2005 was a combination of withholding reimbursement (for hospital acquired conditions), assigning mandatory indicators (‘Present on Admission’ flags), and incentivising best practice (through ‘value-based purchasing) (Wilson, 2009). In order to achieve the requirements of the legislation, CDI programs in the US focused on improving the clinical documentation in the medical records so that resultant coded data submitted to internal and external agencies were as complete and accurate as possible, so as to manage the direct impact on reimbursement (Wilson, 2009).

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