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Effective Clinical Documentation Integrity Processes

Mechanics of Chart Review Process


Any clinical documentation integrity initiative must embrace the concept of proactivity versus reactivity, rejecting the reactive tendency of complacency and content. Proactivity facilitates and supports achievement of measurable meaningful improvement in physician documentation that best serve’s the patient’s and all relevant healthcare stakeholder’s needs for accurate and complete communication of patient care. Referring to proactivity, I subscribe to the notion of opening and reviewing a medical record at time of admission or as close to the hospital entry point as feasibly possible. Today’ CDI process of retrospectively reviewing a record for sake of identifying clinical clues warranting a query clarification simply will not suffice with current heightened need for more complete and consistently concise documentation dictated by present adoption of transformative healthcare delivery models. The underlying principles of CDI that we must incorporate into our regular thought processes include assisting physicians adhere to the Hippocratic Oath:


  • “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”


The following point that appears on the High Value Practice Academic Alliance website outlining the organization’s Founding Principles is directly relevant and plays into the underlying role of a clinical documentation integrity specialists:


  1. Medicine is a public trust, and to maintain the trust that the public places in physicians and other health care workers, medical providers have a responsibility to improve value in health care (HVPAA Founding Principles)


So how does CDI as a profession both individually and collectively take the initiative to assist physicians in improve actual value in health care and demonstrate keen financial stewardship to the patient? Rather than focusing upon the endpoint of reimbursement and case-mix, we should be focusing upon advocating for, promoting and achieving more effective documentation by working closely with physician’s as constituents, engaging them as willing participants. This can be accomplished and furthered through recognition of the immediate need to alter our approach to chart review consisting primarily of “after the fact” knee jerk transactional mentality looking for additional diagnoses reporting or clinical specificity. I am certainly not downplaying the importance of complete and accurate diag