Adopting a modern clinical documentation improvement (“CDI”) strategy can make a difference in the time and energy it takes to finish note-taking.

While CDI started as a billing-focused initiative decades ago, it's evolved far beyond that for today’s clinicians.

According to the Centers for Medicare & Medicaid Services, the evolution of CDI is closely linked to the introduction of ICD-10 coding and the very real shift toward value-based care. These both require detailed, clinically accurate documentation to support quality reporting and reimbursement.

Today’s CDI practices leverage:

• AI-powered medical scribing tools
• Automated EHR workflows
• Interdisciplinary collaboration

... to reduce the burden of clinical documentation while improving the quality of documentation.

This gives your clinic notes and patient letters that truly reflect the care delivered, preserve your voice, and track the patient journey.

In this guide, we’ll break down what CDI is, why it matters in modern medicine, and how to implement a data-driven, clinician-focused CDI strategy that improves compliance and accuracy. 

What is clinical documentation improvement?

Clinical documentation improvement is a systematic approach to ensuring that patient notes accurately reflect the care you provide. It involves:

• Reviewing medical documentation
• Clarifying information
• Improving medical coding 
• Promote CDI best practices 

At its core, CDI focuses on improving both the quality of documentation and the process of creating it. CDI is not about turning every clinician into a coding expert. 

There’s a common misconception that CDI is only for large hospitals with dedicated coding departments. That’s incorrect. Whether you're a solo practitioner or part of a 10-person group practice, CDI principles can apply. 

According to SNS Insider, The CDI market was valued at $5.13 billion in 2023, and is expected to reach $9.96 billion by 2032. This growth reflects an increasing demand for sophisticated CDI solutions. Providers are motivated to invest in CDI solutions that minimize errors and enhance patient care quality. 

Modern CDI isn't about memorizing ICD-10 codes or satisfying hospital administrators. It's about creating clinical documentation that serves multiple purposes:

• Telling a patient's story clearly
• Supporting clinical decisions 
• Protecting a clinic or clinician legally 
• Ensuring fair reimbursement for services

A history of clinical documentation improvement 

CDI has evolved alongside healthcare itself — moving from a billing-focused tool to a system that supports clear communication, better care, and fair reimbursement.

Pre-1980s: CDI's foundation

Prior to the 1970s, patient records were narrated and written by hand. There was little to no standardization. Most clinicians followed a fee-for-service reimbursement model without relying too much on documentation quality. 

In the early 70s, Dr. Larry Weed, a scientist turned physician, toured universities to illustrate the importance of structured clinical data. His idea that "the very structure of the data determines the quality of the output" became a cornerstone of modern medical documentation.

1980s: CDI for billing

In 1983,  Medicare introduced Diagnosis-Related Groups (DRGs) in an effort to control the increasing cost of healthcare. It created a prospective payment system and integrated documentation with reimbursements.

As a result, patient records directly impacted payments. Here's where we first saw clinical documentation improvement. The goal? To accurately reflect the complexities of patient care in billing.

1990s-2000s: The electronic health record

‍Electronic health records (EHRs) showed up in larger healthcare organizations and hospitals — then made their way to clinics. This was a blessing and a curse. Medical documentation became both more standardized and complex.

CDI programs were in full swing in the 90s, and made it to hospitals across the U.S. by the early 2000s.

2010-present: Clinical evolution

With value-based care emphasizing quality and outcomes, CDI has grown beyond billing to support clinical communication, patient safety, and documentation integrity.

Today, CDI has two names: clinical documentation improvement and clinical documentation integrity. 

The clinical profession has evolved to focus on how medical records deliver enhanced patient care and compliance with regulations.

Why clinical documentation improvement matters for clinicians 

CDI isn’t about making you a better clinician. You're already doing excellent work within constraints that weren't designed with you in mind. CDI is about giving you the freedom to do what you do best, without drowning in documentation. CDI is more important than ever because it improves:

Patient care quality

 When your documentation clearly captures what happened during patient encounters, it creates seamless handoffs between providers, shifts, and care settings. Your notes become the foundation for evidence-based decision making. 

When the next provider sees your patient, they understand not just what you diagnosed, but why you made that clinical decision. That's how you protect continuity of care without having to be available for every question.

Billing accuracy

 CDI bridges the gap between clinical language and coding requirements. More accurate notes mean you get paid fairly for the care you actually provided. Research shows a 3.2% increase in expected reimbursement when CDI programs properly document comorbidities — that's real money that was already yours.

Here’s proof: In a study, researchers found that the implementation of a CDI program at a community hospital resulted in a 3.2% increase in expected reimbursement. This was primarily attributed to improved documentation of comorbidities. 

Legal protection 

Your notes are your strongest defense if questions arise about patient care, whether that be through an audit or a potential lawsuit. When your documentation follows CDI best practices, it clearly shows your clinical reasoning and commitment to quality standards. In these ways, CDI reduces legal vulnerabilities 

Shared understanding across your team

When your documentation follows CDI principles, everyone who touches the patient record — nurses, specialists, coders, quality reviewers — can quickly understand the status. Think of it as writing notes that answer questions before they're asked.

The bottom line? Good notes make everyone’s job easier.  Clinical documentation software handles the structure and formatting. With a lighter documentation, everything else gets better.

“This service has changed my life and documentation for the better. I use it in office, for telehealth, and for house calls and it works incredibly well.” - Elizabeth Hayes, PA and Owner, Nomad Clinical Services

What barriers get in the way of clinical documentation improvement? 

CDI sounds great in theory. Better notes, clearer communication, fair compensation. But if CDI is so obviously beneficial, why do many clinicians still resist it? Certain barriers can stand in the way:

1. Old habits: Most clinicians have written notes a certain way for years, and don’t want to suddenly change their approach. While CDI doesn’t require a clinician to abandon what works, it’s understandable that some hold that misconception, especially when many CDI programs start by telling clinicians they're doing it wrong. 
2. Bureaucracy: Clinicians don’t want more forms or boxes to check. We learned that traditional CDI programs were designed by billing departments, focused on capturing the right ICD-10 codes. No wonder clinicians saw it as just another administrative burden.
3. Technology aversion: Many tools marketed as "documentation solutions" actually make life harder, with bad UX, ill-suited templates, and overly generic note-taking settings. When technology adds friction instead of removing it, clinicians rightfully become skeptical.
4. Change management:  Even when clinicians want better documentation, change is hard. The current process might not be perfect, but at least it's predictable. 

Is clinical documentation improvement HIPAA-compliant and secure?

CDI must always be HIPAA-compliant. Improving documentation should never come at the expense of patient confidentiality or data security. Any CDI process or technology should meet the same security standards as your EHR. At a minimum, it should:

• Protect patient data with encryption (both in transit and at rest)
• Enforce role-based access controls and maintain audit logs
• Comply with HIPAA’s Privacy Rule and Security Rule
• Require Business Associate Agreements (BAAs) with any vendor handling protected health information (PHI)

If you’re using digital or AI-powered documentation tools as part of your CDI workflow, it’s especially important to understand:

• Where patient data is stored
• How long it is retained
• Who can access it
• Whether and how the data is used for model training

The bottom line: if a CDI workflow or vendor can’t clearly explain how they protect patient data and support HIPAA compliance, they don’t belong in your clinical workflow.

Specialty-specific clinical documentation improvement guidance

Every medical specialty has its own documentation challenges, and a one-size-fits-all approach to CDI rarely works.

Primary care, mental health, urgent care, and specialty practices each have different workflows. Understanding these differences is key to implementing effective CDI strategies.

This chart highlights examples of what “good” documentation looks like in each specialty.

Clinical documentation improvement: Case studies

Dr. Cecily Kelly, a Texas family medicine practice owner seeing over 270 patients weekly, used to struggle with charting backlogs, long after-hours documentation, and mental exhaustion from trying to remember every patient detail. After adopting Freed, she regained control of her time and focus, completing charts during the day, preparing for visits with smart summaries, and leaving work when her last patient did.

For Dr. Kelly, Freed’s ambient AI scribe captures all of the details, while allowing her to edit notes anywhere and stay fully present with patients. Freed transformed her workflow from late-night charting to true work-life balance.

Another clinician, Dr. Sam Broffitt, was burning out from long nights of dictation and exhaustive documentation after 40 years of practicing medicine.

Using Freed’s clinical documentation transformed his workflow. He now brings a laptop into visits, lets Freed capture conversations in real time, and makes only light edits before leaving work on time. Freed enables him to focus entirely on his patients, create more accurate and complete notes, and even have down-coded claims reversed due to improved documentation quality.

With 8–10 hours a week back in his schedule, Dr. Broffitt enjoys two evening rounds of golf and a rekindled love for medicine, saying Freed has helped him not only practice “better medicine” but also rediscover joy in his career.

Clinical documentation improvement is a big opportunity for small practices 

Many CDI resources are written for 200-bed hospitals with dedicated coding teams and IT departments. If you're a solo practitioner or part of a 2-10 clinician practice, that guidance feels irrelevant. 

Small practices need simpler, more practical CDI approaches. You don't need enterprise dashboards or dedicated staff. You need solutions that work immediately, without requiring IT teams or months of implementation.

47% of Freed users are small and medium practices because the technology finally makes high-quality documentation accessible without the infrastructure overhead. Simple browser extensions, flexible per-seat pricing, and setup that takes minutes instead of months — that's how small practices can level up their documentation with less effort, not more.

How do you launch a clinical documentation improvement program? 

HIMSS Analytics reports significant growth in the CDI technology market, with organizations increasingly integrating AI-driven solutions to improve documentation accuracy, compliance, and clinician satisfaction, making CDI a strategic investment. CDI programs can flip the script for clinicians who've spent one too many evenings charting patient visits. Follow these best practices to build a CDI program. 

1. Start with what’s working — and what’s not

Start by evaluating where you stand today in terms of documentation. Create a small sample of recent patient charts. Review these records specifically for documentation gaps like:

• Missing/unclear diagnostic specificity
• Discrepancies in assessment and plan 
• Incomplete explanation of medical necessity
• Insufficient information about the condition

A targeted review will highlight documentation patterns draining your time and impacting your notes.Use this analysis to set clear, concrete goals for your CDI program. 

Focus equally on metrics that impact your life as a clinician, such as time spent in after-hours charting and CDI queries. Your CDI goals should balance better documentation with better clinician well-being.

2. Teach CDI without the headache

Help everyone understand the purpose of a CDI program, without overwhelming them. Communicate how a CDI framework directly impacts the quality of documentation and benefits patients and clinicians alike. 

There are a few ways to do that:

• Connect CDI to outcomes that clinicians already care about
• Offer bite-sized, specialty-specific resources that feel relevant
• Run training sessions that respect clinicians' time (30 minutes max)

Make training materials available on-demand. This would allow providers to reference these guidelines when they’re actually creating patient records. 

Pro tip: Schedule training when clinicians are starting their shift with a fresh mindset, not at the end of a marathon shift. Protected time beats rushed learning every time.

3. Design a workflow that flows

For your CDI program to succeed, you need processes that complement rather than complicate your clinical workflow. Map your documentation journey from start to finish and identify where improvements can slide in naturally. 

Another solution is to use templates to jumpstart the documentation process in a snap. These standardized templates contain a clear structure to give you a quick headstart and save you the trouble of preparing everything from scratch. 

You can also create a clear, non-disruptive process to raise queries for clarification. This process should respect the clinician's time and cognitive energy.

Templates are a solid start, but AI scribes makes it even easier. Freed listens to your patient interactions and turns them into structured notes — complete with CDI best practices — so you can skip the late-night charting.

Freed records your patient interactions and automatically generates structured notes within minutes. With Freed, you can:

• Prepare patient notes in real-time, adhering to CDI guidelines
• Generate notes that reflect your personal style and preferences
• Directly integrate with EHRs like Athena, eClinical Works, and Practice Fusion
• Ditch those late-night charting marathons and spend time with your loved ones

Clinical documentation improvement best practices 

As you optimize your CDI systems, remember the following: 

1. Focus on consistency, not perfection: Your notes don't need to be literary masterpieces, but they should consistently capture what you observed, what you decided, and why.  Clinical notes examples show that effective documentation follows predictable patterns that make information easy to find and understand.
2. Set preferences that work for you: Whether you prefer detailed SOAP notes, concise summaries, or specialty-specific templates, the key is consistency. Use clinical documentation software that learns your style instead of forcing you to adapt to rigid formats.
3. Let tech handle the structure: Modern clinical documentation AI can manage formatting, organization, and CDI compliance automatically. This frees you to focus on the clinical content that only you can provide, like your assessment, reasoning, and care plan.

Clinical documentation improvement should be clinician-first

Clinical documentation improvement works best when it is designed around how clinicians actually practice medicine — not around billing workflows or administrative checklists. The goal of CDI is simple: create clinical notes that are clear, accurate, defensible, and efficient to produce.

Effective CDI should reduce documentation burden. The best clinical documentation improvement workflows streamline note structure, formatting, and organization so clinicians can focus on patient care instead of screens and templates.

This is where clinical documentation AI  and ambient clinical documentation are changing how CDI is implemented in real-world practices. These tools support compliant, structured documentation in the background while clinicians focus on the patient encounter itself.

As one family medicine physician shared:

“Freed is nothing short of revolutionary. Focusing exclusively on the patient and not on typing notes has not only given me back my life, but has also re-sparked the joy of practicing primary care.” - Dr. Bryan Walker

The Clinical documentation improvement checklist

Use this checklist to quickly evaluate whether your clinical documentation meets CDI best practices:

This checklist is intended as a general guide and is not a substitute for legal or compliance advice.

If you can check most of these boxes consistently, you're helping your team follow clinical documentation improvement principles. If not, this checklist highlights exactly where your notes — or your workflow — need support.

Ready to optimize your clinical documentation improvement? 

The goal of CDI is to create a workflow where good documentation happens naturally. Try for free to see for yourself.