Top 30 Best Clinical Documentation Improvement (CDI) Software

As a physician, protecting patient privacy is a core responsibility. To support this commitment, Clinical Documentation Improvement  software helps keep healthcare records accurate and consistent. It checks that clinical terms and coding align correctly, which improves the quality of documentation and supports compliance with medical standards. As the healthcare industry shifts, there’s growing pressure to keep records more precise and detailed. CDI software plays an essential role in responding to these demands. It ensures that medical records truly reflect the care provided, helping providers meet regulatory expectations and deliver better outcomes.

This technology also supports consistent documentation practices across the board, lowering the chances of mistakes that could trigger audits or claim denials. In doing so, it helps create a safer, more reliable environment for both patients and providers. Here are top 30 clinical documentation improvement software.

Top 30 Best Clinical Documentation Improvement (CDI) Software

1.  Kohezion

Kohezion Clinical Documentation Improvement (CDI) software helps healthcare providers improve how they manage clinical records. It offers a cloud-based setup that keeps documentation accurate, organized, and in line with compliance rules. Because it stores data in a HIPAA-compliant environment, patient records remain secure and confidential. Users can adjust the system to match specific workflows, but they may need some training to use all the available features effectively. Although Kohezion simplifies the documentation process, it may not match the advanced AI tools found in some newer solutions.

Pros

• Improves coding precision and reduces documentation mistakes
• Helps meet compliance standards

Cons

• Requires training to fully use its customization tools
• Lacks some of the advanced AI features other platforms offer

2. Nuance 

Nuance CDE One is a CDI platform that uses artificial intelligence to support encounter prioritization, task management, and data analysis. It helps CDI teams work more efficiently by offering insights and content grounded in clinical evidence. The platform cuts down on administrative tasks, improves how quickly reports are completed, and helps ensure that documentation is more accurate and consistent.

Pros

• Finds relevant cases automatically
• Supports early query handling
• Helps manage claim denials
• Includes a searchable coding tool

Cons

• May be costly for smaller healthcare providers

3. Iodine 

Iodine’s AwareCDI Suite uses artificial intelligence to make clinical documentation improvement more accurate and consistent. It helps CDI teams focus on the most financially impactful cases, cutting down manual work and reducing the risk of coding mistakes. This approach supports hospitals in protecting their revenue while meeting care and compliance standards.

Pros

• Helps boost revenue capture
• Minimizes manual coding mistakes

Cons

• May be expensive for smaller hospitals
• Staff need training to fully use the AI features

4. 3M

3M Advanced CDI brings together clinical documentation, physician input, coding, and quality review in a single platform. Using artificial intelligence, it helps healthcare providers improve the accuracy of patient records and maintain compliance with regulations. The system also checks documentation and codes during entry, helping hospitals catch errors early and avoid financial setbacks. Hospitals use it to cut down on duplicate work, follow documentation rules more closely, and receive proper reimbursement for services. While it improves documentation practices and overall care quality, smaller hospitals may find it expensive, and staff may need time to learn how to use it effectively.

Pros

• Helps lower the chances of denied claims and audits
• Contributes to improved patient care

Cons

• May be too expensive for small healthcare providers
• Users often need training to get started.

5. Optum

Optum Physician EHR Software gives healthcare providers secure access to electronic medical records while staying compliant with HIPAA standards. It supports physicians in managing patient care more efficiently through clinical documentation tools and built-in practice management features. While some users have noted occasional system delays, the software remains a practical option because of its clean interface and flexible documentation options that adjust to different medical specialties.

Pros

• Offers detailed tools for managing patient information and documentation
• Allows customization of templates to suit various medical specialties

Cons

• New users might need time to get used to the system
• Occasional lagging has been reported

6. Dolbey Systems

Dolbey’s Fusion CAC makes it easier for CDI teams to spot documentation gaps and take action quickly. It uses AI and machine learning to scan medical charts, prioritize the most urgent cases, and deliver alerts that guide specialists during reviews. This helps hospitals keep documentation accurate, meet regulatory standards, and avoid missing out on proper reimbursement. It also supports better patient outcomes by reducing errors in clinical records. The tool works well for day-to-day CDI tasks and simplifies the process of identifying where clinical documentation can be improved.

Pros

• Alerts and prioritization help CDI teams focus on the most important cases
• Connects well with EHRs and includes detailed reporting features

Cons

• Larger organizations might require adjustments to fit specific needs.

7.  Nthrive

nThrive clinical documentation improvement software helps improve the accuracy and depth of patient records, which in turn supports better reimbursement outcomes and reduces audit risks. It supports collaboration between clinicians, documentation specialists, and coders to make sure medical records reflect the full scope of a patient’s condition. This online platform uses tools like artificial intelligence, natural language processing, and electronic health record integration to capture detailed clinical information, from diagnoses to subtle treatment details.

Pros

• Offers feedback and coding suggestions that improve documentation clarity

Cons

• Requires extensive training and adaptation to use effectively

8. Streamline Health Solutions

Streamline Health helps hospitals improve documentation accuracy and recover missed revenue. It simplifies daily tasks for Clinical Documentation Improvement Specialists (CDIS) by automating assignments and allowing side-by-side reviews of coding or DRG scenarios. This setup helps users quickly spot areas that need documentation corrections or enhancements. The software works with a hospital’s ADT system, so assignments show up automatically each day, helping CDIS stay on track. Users can also access the platform remotely, which makes it easier to complete reviews outside the hospital. Additionally, it includes automated queries for physicians, which can help reduce delays and boost the quality of patient records and financial outcomes.

Pros

• Promotes consistency across clinical documentation
• Helps clinicians work more efficiently

Cons

• Requires significant support from IT and clinical teams

9. Solventum

Solventum offers a software that helps healthcare providers improve how they capture and manage clinical documentation. It focuses on simplifying documentation tasks, making it easier for care teams to enter accurate information, stay compliant with industry regulations, and avoid revenue delays. The software includes helpful tools such as ICD-10 coding assistance, documentation feedback as clinicians work, and detailed analytics for performance tracking. Healthcare teams can access the system remotely, making it practical for distributed care environments. It also meets HIPAA standards for patient data security, giving users confidence in handling sensitive information.

Pros

• Allows access from different locations, supporting teamwork across facilities
• Makes documentation easier and more accurate

Cons

• Does not include advanced AI functionalities
• May need adjustments to fully meet the needs of large health systems

10. Cerner 

Cerner’s Clinical Documentation Improvement approach brings physicians, documentation specialists, and coders together within the Cerner Millennium platform to improve the accuracy of clinical records. This collaboration helps ensure that documentation clearly reflects the patient’s condition and justifies the diagnoses and treatments provided, which is essential for appropriate reimbursement. Cerner supports both the clinical and financial aspects of documentation by helping healthcare teams capture the detail needed to back up coding decisions. This connection between front-line care and back-end processes can lead to better documentation quality and more accurate billing.

Pros

• Helps meet regulatory standards
• Improves coordination between clinical teams

Cons

• May be too expensive for smaller practices
• Requires training to maximize its use

11. AGS Health

AGS CDI from AGS Health uses artificial intelligence to improve the accuracy of clinical documentation. It reviews digital patient charts and flags possible documentation gaps, then suggests queries that help healthcare professionals clarify information. The system also alerts users about key quality issues, encouraging better collaboration among clinical, coding, and health information teams. Over time, this helps healthcare organizations improve documentation practices, meet compliance requirements, and maintain consistent revenue.

Pros

• Smart worklists that prioritize documentation tasks
• Automatic suggestions for query improvement
• Useful reports that support CDI decision-making

Cons

• Setup and onboarding may take time
• May be expensive for smaller practices or facilities

12. EvidenceCare

EvidenceCare’s AdmissionCare helps clinicians ensure accurate documentation of medical necessity during patient admissions. It allows providers to input bed status criteria and push orders directly into electronic records like Epic and Oracle Cerner. It also offers documentation support that helps Utilization Review teams quickly access the required information. By integrating with existing EHR systems, AdmissionCare improves how physicians collaborate, supports better decision-making, and helps hospitals avoid financial loss due to incorrect documentation.

Pros

• Helps cut down on medical necessity denials and documentation errors
• Makes handoffs between emergency and inpatient teams more efficient

Cons

• Limited options for customization
• May encounter issues during integration with existing systems.

13. Clarity CD

Clarity CD software helps healthcare providers move patient information from various document types including typed text, handwritten notes, faxes, and PDFs into the correct electronic health record without requiring manual input. This reduces the risk of errors and speeds up the process. It uses natural language processing and artificial intelligence to pull out important patient details, such as demographics and clinical data. Then it organizes the data into a Continuity of Care Document and transfers it securely through Consensus’ Direct Secure Messaging. This automated process makes it easier for healthcare professionals to access accurate patient information when they need it.

Pros

• Speeds up how quickly patients receive care
• Can fit into growing systems as needs expand

Cons

• May be expensive for smaller practices

14. Vizient

Vizient’s clinical documentation improvement software plays an important role in helping hospitals and healthcare providers meet national reporting requirements, such as Present on Admission indicators, Pay-for-Performance programs, and Value-Based Purchasing. These programs demand precise and specific clinical documentation, which Vizient supports through its data-driven approach.

Using its in-depth analytics capabilities, Vizient quickly identifies documentation gaps and helps healthcare teams make informed changes that can lead to measurable improvements. Its system evaluates clinical data across service lines, procedures, and individual physicians, giving users clear, comparative insights into performance. With access to risk-adjusted benchmarking, organizations can view where they stand and take meaningful steps toward improvement.

Pros

• Includes performance data for comparison and improvement
• Provides insights across physician, procedure, and service-line levels

Cons

• May involve a steep learning curve during implementation
• Can be expensive for smaller organizations with limited budgets

15. bestPT 

bestPT is a cloud-based software that helps physical therapy clinics run their daily operations more efficiently. It brings together everything from documentation to billing in one platform, helping therapists stay organized and productive. With tools that guide users while writing patient notes, the system simplifies clinical documentation and reduces time spent on administrative tasks. The document module supports accurate SOAP note creation and provides useful prompts to make the process faster and easier.

Pros

• Offers fast note-taking with pre-made templates and custom macros
• Claims workbench keeps billing tasks sorted and improves clinic workflow

Cons

• The amount of information available at the start can feel overwhelming to new users.

16. PatientNotes.Ai

PatientNotes.Ai is an ambient clinical documentation tool that listens in the background during patient visits, automatically capturing conversations and converting them into well-structured notes. With an impressive 97.8% accuracy in recognizing medical terms, it understands the flow of clinical dialogue and organizes notes according to the SOAP format. It doesn’t just transcribe words it interprets the meaning behind them, accurately capturing nuanced assessments and care plans that often go unnoticed with traditional tools. Healthcare providers across different specialties benefit from its intelligent note creation, supported by specialty-specific templates and a built-in quality check system that helps improve documentation accuracy and efficiency.

Pros

• Includes specialty-specific templates
• Built-in validation helps improve documentation quality

Cons

• May face limitations when integrating with some EHR systems

17. Freed AI

Freed AI simplifies clinical documentation by focusing on speed and ease of use. It offers a straightforward three-step process: record the conversation, generate the note, and review the output. This makes it a practical option for smaller medical practices that want to start using AI without going through a complicated setup. The system produces SOAP notes that follow established medical guidelines and can also generate After Visit Summaries. It works on a secure, HIPAA-compliant platform and promises to generate notes in about 60 seconds.

Pros

• Easy to adopt for small practices
• Fast documentation turnaround (around 60 seconds)
• Follows medical documentation standards
• Built on a HIPAA-compliant system

Cons

• Users often need extra time to edit the generated content

18. MarianaAI 

MarianaAI’s CARE platform helps simplify clinical documentation using AI tools that assist healthcare providers throughout the patient care process. Its AI Medical Scribe captures and transcribes medical conversations in multiple languages while automatically generating notes and medical codes. The platform also compiles a clear summary of each patient’s history through its Patient Portrait feature, helping clinicians make better decisions and improving coding accuracy for HCC and RAF scoring. CARE also handles repetitive tasks like drafting patient messages and organizing triage communications, allowing clinicians to focus more on patient interaction than paperwork.

Pros

• Supports multiple languages
• Automatically codes using ICD-10 and CPT standards
• Learns and adapts to clinician speech patterns
• Offers various note templates (SOAP, BIRP, DAP)

Cons

• Setup may require a significant upfront investment

19. Heidi Health

Heidi Health uses artificial intelligence to help healthcare providers quickly produce clinical notes during patient visits. It listens to conversations between the patient and clinician, then generates documentation based on that interaction. The software pulls appointment information from the EHR system into its platform to create notes, but it doesn’t send any data back into the EHR. This setup keeps things simple but may require extra steps if edits or updates need to reflect in the original record.

Pros

• Automatically creates medical notes from conversations
• Offers editable templates for different specialties

Cons

• Sometimes experiences issues with templates or misheard details in transcription

20. Abridge

Abridge is an AI-powered documentation tool that captures and converts conversations between patients and clinicians into structured notes that are ready for review and billing. It listens to audio during medical visits and uses its Automated Speech Recognition system to produce transcripts. Then, a Contextual Reasoning Engine processes the content, highlighting medical concerns and aligning the language to match clinical and billing requirements. Clinicians can make changes, approve, and sign off on the generated notes directly in their electronic health records.

Pros

• Speeds up documentation and reduces manual note-taking
• Helps maintain billing accuracy by aligning notes with codes
• Lets clinicians edit and sign notes without leaving the EHR

Cons

• May not integrate smoothly with all EHR systems

21. ChartWise

ChartWise Medical Systems, Inc. offers a cloud-based solution that supports Clinical Documentation Improvement with the help of AI and smart language processing tools. The platform simplifies the way physicians document patient encounters, making it easier to align their notes with coding and billing standards. It translates clinical notes into accurate diagnostic codes, improving documentation quality while supporting compliance with healthcare reporting requirements. The system includes features such as natural language processing, dual-query support for both ICD-9 and ICD-10, and analytics to guide documentation improvements. It also works well with electronic health record systems and keeps patient data secure under HIPAA guidelines.

Pros

• Helps doctors match clinical notes with billing codes more accurately
• Uses NLP and analytics to improve documentation
• Supports ICD-9 and ICD-10 code queries at the same time
• Works securely within existing EHR systems

Cons

• May not meet the needs of larger healthcare organizations

22. Enzo Health

Enzo Health brings together multiple essential documentation tasks into a single platform, allowing home health providers to manage intake, scribing, coding, and quality assurance all in one place. With a focus on home health, its AI scribe automatically creates OASIS assessments, care plans, and narratives, helping clinicians spend more time with patients instead of paperwork. The platform’s built-in coding and QA tools help catch documentation errors early, improving accuracy and reducing the risk of compliance issues during audits.

Pros

• Produces clear, audit-ready clinical notes that lower compliance risk
• Uses clinician-reviewed AI to catch coding mistakes before claims are submitted

Cons

• Staff may need time to get used to the system.

23. Evidently CDI

Evidently CDI works alongside EHRs to improve how patient care is documented. It helps healthcare providers record accurate and complete information, which supports better care delivery, reduces documentation errors, and improves how facilities report and bill for services. This tool also helps hospitals stay aligned with regulatory expectations and makes it easier to secure appropriate reimbursements by keeping records clear and consistent.

Pros

• Reduces chances of non-compliance and audit penalties
• Improves documentation accuracy for billing and reporting

Cons

• Demands significant time and resources to set up and maintain

24. Ambience CDI 

Ambience uses AI to help clinicians improve how they document care and choose medical codes. It adapts to the unique coding requirements of over 100 medical specialties and subspecialties, supporting both traditional billing systems and value-based models. The tool presents suggested codes during the patient visit, allowing clinicians to quickly review and approve them. It also structures the documentation to back up the chosen codes, which helps reduce errors and improves compliance with coding standards across the revenue process.

Pros

• Adapts to specialty-specific workflows for note creation and coding
• Connects with major EHR systems
• Meets HIPAA and GDPR privacy standards

Cons

• Occasionally produces minor errors in transcription

25. AKASA Coding

AKASA Coding uses generative AI and large language models trained on each health system’s specific data to assist with medical coding and clinical documentation improvement. It reviews clinical notes, recommends the right codes, explains its choices with supporting evidence, and identifies potential gaps in revenue or documentation quality. The system fits into existing workflows to help coders work faster and more accurately, while also cutting down on errors and operational costs. It combines automated learning with expert oversight to manage exceptions and ensure ongoing refinement.

Pros

• Adapts to unique organizational data
• Encourages coder development through supportive insights

Cons

May lead to overdependence on AI systems

26. Regard Health

Regard Health offers a clinical insights platform that uses AI to pull together all patient information stored in electronic health records. It brings the most relevant details to the surface, suggests possible diagnoses for both acute and chronic conditions, and recommends treatment options. Acting like a digital assistant, it scans and interprets both structured and unstructured data to help clinicians spot safety issues or overlooked diagnoses. It also helps produce clear, traceable documentation. The platform connects directly with major EHR systems, helping reduce time spent on documentation and improving billing accuracy, which can positively impact hospital revenue.

Pros:

• Improves the accuracy and completeness of patient records
• Helps reduce claim denials and speeds up billing

Cons:

• Can involve a steep learning curve for new users

27. SmarterDx

SmarterDx uses artificial intelligence to review hospital patient records before billing, helping medical teams catch gaps in documentation and improve coding accuracy. It scans provider notes, lab results, medications, orders, vital signs, and imaging studies using hundreds of clinical algorithms. After analyzing the data, it suggests improvements backed by clinical evidence, giving documentation teams the chance to review and confirm the suggestions before the records are finalized. This early-stage review helps improve both billing accuracy and quality reporting without disrupting provider workflows.

Pros

• Helps hospitals capture missed revenue opportunities
• Offers evidence-backed suggestions to support documentation reviews
• Enhances coding accuracy and compliance

Cons

• May require complex integration with existing health IT systems
• CDI teams might need time to adjust to AI-based workflows

28. Accuity 

Accuity focuses on improving the accuracy of hospital documentation through a physician-led review process supported by technology. It works as a pre-bill review system that helps hospitals identify missing or unclear clinical information before submitting claims. This results in more precise coding, better reimbursements, and fewer billing errors. The platform also offers tools that use data insights to flag incomplete documentation and provides peer-level education to guide clinicians in correcting those gaps. Additionally, it helps healthcare teams address clinical denials more effectively, which contributes to stronger overall outcomes.

Pros

• Easy to adopt with clinician education included
• Helps improve documentation accuracy before billing

Cons

• May be expensive for some healthcare facilities

29. DeepScribe

DeepScribe is a clinical documentation tool that fits well into busy healthcare settings. It works smoothly with scheduling software and performs well during routine patient visits. For more complex cases, however, it might require closer supervision to ensure accuracy in documentation. The system includes speech recognition and integrates with EHR platforms, which helps reduce the time clinicians spend writing notes.

Pros

• Easy-to-use interface that supports quick navigation
• Works with telemedicine platforms to capture remote visits
• Uses ambient AI to assist with documenting patient encounters

Cons

• New users might need time to adjust
• Some features may be tricky to customize without technical support

30. Phreesia

Phreesia brings patient intake and clinical documentation into a unified process, simplifying how clinics handle appointments from the moment a patient checks in to the end of the visit. This setup benefits clinics that want to improve how they gather patient information while keeping their documentation accurate and updated during care. Instead of relying on separate systems for intake and records, Phreesia keeps everything in sync, making each step feel more connected and less repetitive for healthcare staff. Phreesia helps clinics aiming to improve how they collect patient data and document visits in one system.

Pros

• Combines intake and documentation in one workflow
• Uses natural language processing to capture medical history
• Syncs well with electronic health records

Cons

• Some users report a clunky or confusing interface.

Clinical documentation improvement software has evolved significantly. It’s no longer just a tool for transcription; it now plays an active role in improving documentation accuracy, supporting better coding, and helping reduce clinician fatigue. Today, CDI systems contribute to clearer records, better communication, and higher quality patient care. This article highlights thirty leading CDI solutions to help you find one that aligns with your team’s needs, priorities, and improve management of a hospital network or guiding documentation practices in a single clinic.