Clinical Documentation Improvement Managers (CDIMs) continually monitor the success of their healthcare organization’s CDI program. The metrics they use commonly include volume of queries issued, query success, case mix data, severity of illness, and risk of mortality data. However, there is another critical element that should be monitored by the CDIM: clinical documentation validation.Clinical documentation validation risk assessments should be regularly conducted to identify documentation weaknesses which lend themselves to coding compliance risk.
Here are my thoughts….
- A clinical documentation validation risk assessment should be performed quarterly.
- Best practice is to audit a sample of medical records from high volume service areas. Sample assessment questions are listed below.
- Use audit results to identify documentation risks and create educational opportunities.
Sample clinical documentation validation assessment questions:
- Is there clinical evidence in the medical record to support physician documented diagnoses and procedures?
- Are diagnoses and procedures documented in the progress notes and body of medical record documented in the discharge summary?
- Are diagnoses consistently and continuously documented in the progress notes and body of the medical record?
- Does the documentation support the highest level of code specificity assignment?
- Does the attending physician’s note consistently link to the resident’s and consultant’s notes? (i.e., attending physician documents Bacteremia, while the resident and consultant document Sepsis)
With regards to the collaboration between your CDI program and your coding compliance program, what are your thoughts?