CDI Review Documentation Requirements

msiebert@lhs.org

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

msiebert@lhs.org

Also if you prefer to email me with your input - msiebert@lhs.org

lprescott1

Members of the board are presently writing a document on CDI record review- to include what the CDI should be documenting within this process. It should be out in a few weeks.