CDI Review Documentation Requirements
I thought I would ask if documentation requirements for CDI reviews have been discussed and or established at facilities/health systems. We are currently looking toward standardizing our CDI documentation. Any assistance or thoughts will be helpful.
I thought this could be a topic of discussion since queries for new diagnoses requires documentation of clinical evidence as well as what evidence is documented (in the pt’s record) for a rule-out-a-diagnosis query. Has any organization require CDI review documentation to include clinical evidence along with the diagnoses? If so, is there standardized documentation between CDI reviewers at your facility/health system? If so, do you mind sharing your CDI documentation requirement guidelines?
Thank you, Molly Siebert, Portland, Oregon