The CDS is responsible for facilitating the overall quality, completeness, timeliness, and accuracy of clinical documentation in the patient record. This supports the delivery of highquality patient care, hospital accreditation and adherence to quality standards, the clinical coding process, and appropriate hospital funding. The role of the CDS is generally broken down into three major aspects:

• Comprehensive review of patient medical records, whilst the patient is an inpatient, to identify gaps within the clinical documentation. This is called concurrent CDI, in contrast to the retrospective queries that coders generate. The reviews are then used to create opportunities to engage with clinicians, empowering them to improve their clinical documentation and ultimately provide safer care to every patient. The CDS acts as the bridge between clinicians and clinical coders to facilitate accurate and timely clinical coding. This enhances the integrity of the health service’s data and ensures the health service is financially sustainable.
• Real-time conversations to positively engage with clinicians involved in the patient’s care and close the gaps in their clinical documentation. The CDS provides regular hospital-wide education to clinicians, including doctors, nurses, and allied health professionals, about complete, accurate, and specific documentation that reflects patient complexity and acuity and facilitates accurate coding. The CDS therefore must possess an advanced level of clinical acumen to positively engage with and educate clinicians.
• Overarching development, maintenance, and growth of the hospital’s CDI program, including achieving program objectives and key performance indicators.