Clinical Documentation
Improvement
CDI
Why?
• Your documentation reflects the patient in the
bed, the necessity of clinical diagnostics, the
need for continued length of stay (LOS) and
the quality of care provided.
• The final coded record, which is the outcome
of your documentation, is shared and
available to CMS, data mining agencies and
insurers. The information is also used by the
hospital to evaluate quality, financial
performance and healthcare initiatives for the
organization.
Phraseology …
• The Clinical Documentation Specialist (CDS) is the
liaison between provider documentation and the
final coded record.
• The goal of CDI is to make sure the final codes
accurately reflect the complexity of the patient.
Remember - we are here for you, to discuss an
admission or resource our coding experts to
make sure we “get it right”
Descriptors and Diagnoses
Why clarify? …..
• How “insufficient” is it?
• Do “mild”, “moderate”, “severe” and
“profound” mean the same to each clinician
as a measurable value?
• Do you know that “urosepsis” reflects a
simple UTI in coding?
Symptom Diagnoses
•
•
•
•
“Change in mental status”
Chest Pain
Syncope
Weakness
Link the suspected or known clinical cause to
symptom diagnoses when testing is complete
Continuity …
Example of lack of continuity:
• Admission note: “Acute renal failure
secondary to volume depletion.”
• Progress note: “renal insufficiency,
dehydration.”
• Discharge summary: “patient was admitted
with dehydration…”
Continuity ….
Example of Continuity:
• Admission note: “Acute renal failure
secondary to volume depletion.”
• Progress note: “Acute renal failure,
improving.”
• Discharge summary: “Acute renal failure and
dehydration resolved”
Diagnostic Terms
Clarification of diagnostic terms:
• Avoid use of up ↑ and down ↓ arrows for
abnormal lab findings. Instead, use terms such
as hyponatremia, hyperkalemia, anemia (and
type of anemia)
• Approved abbreviations only … avoid the use
of terms not approved.
Present on Admission “POA”
Present on Admission
• Every diagnosis is assigned an indicator!
• In order to determine whether or not a
diagnosis was present on admission we may
ask for further clarification.
• Clarification is important to identify if a
diagnosis occurred after admission or was
POA … ie: decubitus ulcers, pneumonia, UTI’s
etc..
Query Response
• Please respond to physician queries in one of
two ways:
• If you agree with the question being asked,
please indicate in your progress note and if
appropriate re-address in the discharge
summary.
• If you disagree with the query, please indicate
to us that you’ve seen it.
Clinical Documentation Integrity
If you have any questions about a particular
query, or the program in general, please call
us. We’re happy to help!