Review Documentation - How much documentation is adequate in a review

If you are using a tool for your reviews, CDIS, Epic or another, how much documentation are your CDIs entering as free text, beyond actual Dx and x codes.  Since we implemented Epic, there is much less comment/assessment type documentation than previously.  Is this the norm?


  • One of my pet peeves is poor documentation from CDI's... I mean, we are supposed to be documentation gurus ;-)

    That being said, documentation should not be superfluous. I don't personally even think complete lists of diagnoses are needed. The role of CDI is to identify areas where clarification is needed. So transferring a list of dx from a problem list to a CDI worklist is not very valuable. I typically instruct people to document 'significant' diagnoses but what 'significant' is may be up for debate. To me, anything that impacts the Pdx, and quality-related dx (HACs/PSI's/etc), and CC/MCC's should be listed.  But the more important information is (this list is not exhaustive):

    1. documentation/labs/medications that suggests a condition that is not documented

    2. clinical indicators that support 'at-risk' dx (sepsis/maln/aki/encephalopathy/etc)

    3. Documentation that supports the decision to code/not code a condition as a complication

    4. Documentation that supports POA status for key dx (sepsis, ulcers, etc)

    5. Documentation that explains an evolving understanding of the patients condition

    6. Documentation that supports that a diagnosis was ruled in/out

     Program structure will also have impact. Do you transfer patients amongst CDI's frequently? Do coders have access to, and use, the CDI worksheet? How are worksheets utilized for internal auditing? Is data extracted from CDI worksheets (discrete fields).

    But everything documented on a worksheet should have 'added value'. I have seen CDI's make the mistake of focusing primarily on 'completing the worksheet' while losing site of the actual role/goals of CDI. This is a problem. A worksheet should not simply be C&P of a list of dx, med list, and labs. It should include information that will assist with re-reviews, transfer of information between CDI's, communication with coding, and a record of the CDI's thought process.... Not so different than what we teach doctors ;-)  


  • The ACDIS white paper- How to Conduct a Medical Record Review might be helpful for you.

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