Medical record documentation must be complete and specific in order to:
- Promote better patient care and disease management.
- Accurately reflect the severity of illness (SOI) and risk of mortality (ROM) of the patient. These items have a critical impact on our published quality scores.
- Provide appropriate reimbursement for the care rendered.
How Can a Clinical Documentation Improvement Nurse Assist You?
Our CDI team of nurses possess expert knowledge of clinical care and applicable coding guidelines. They review all inpatient records concurrently to identify opportunities to clarify missing or incomplete documentation. They generate queries, which are written questions with supporting clinical information, to improve the specificity and completeness of the data used to assign diagnosis and procedure codes.
The physician should review the query in a timely manner and document any additional information in the patient’s medical record, not on the query itself. The coding team cannot code from the query form.
The CDI team is available to speak to and/or meet with any physician having questions about a specific query or the CDI process. The contact information for the nurse that generated the query will be located on the query form.