Standardised and reliable best practice in clinical documentation improves the quality, completeness and accuracy of the medical record. Clinical documentation in patient medical records is used for multiple purposes by the hospital and health service; two key purposes include effective communication of the care provided and determining the correct Diagnosis Related Group (DRG) through clinical coding for reimbursement. All healthcare professionals are required to document the care provided accurately and completely in the medical record. Clinical data must be consistently recorded to well-defined national standards to ensure it is fit for purpose.
Incomplete or ambiguous clinical documentation can undermine patient safety, disrupt continuity of care, and lead to the assignment of an inappropriate DRG or complexity level. This may result in inaccurate cost reimbursement and weaken the integrity of data used for health service planning. The clinical documentation-to-clinical coding process involves multiple steps where errors or omissions can occur, with flow-on effects for data quality, funding accuracy, and clinical insight.
Several key points within this process have been identified where information integrity may be compromised:
The Clinical Documentation Specialist (CDS) team at Gold Coast Health addresses these risks by engaging, educating, and supporting clinicians through the ‘e-Ink the Link’ (e-ITL) process. This concurrent, real-time documentation review model allows CDS staff to proactively review patient records mid-admission and issue electronic documentation queries. These queries facilitate timely clarification of ambiguous or incomplete clinical documentation while care is ongoing. Ethical, quality-focused prompts serve as a tool for clinicians to clearly articulate the clinical rationale for care, resulting in improved capture of patient complexity, better clinical coding outcomes, and occasionally even informed clinical action.
The effectiveness of the CDS team lies in the clinical expertise of its members. Each team member has a background in nursing, allied health, or medicine, which provides a comprehensive understanding of diagnoses and management plans, and facilitates identification of insufficiently documented complexity and ambiguity. The diversity of clinical backgrounds brings a valuable range of perspectives to documentation review. This multidisciplinary insight strengthens the team’s ability to interpret medical records holistically and contributes to more well-rounded, clinically relevant documentation improvement.
Since its implementation, the CDS team has grown from 2 to 5 full-time equivalents. Each new team member undergoes targeted training in technical and interpersonal skills needed for effective documentation improvement.
The e-ITL process was introduced in 2021 following the successful implementation of the original Ink the Link (ITL) model in 2020—a concurrent documentation review and query process developed by the CDS team. Initially trialled in a single specialty unit, ITL demonstrated improved capture of clinical complexity and highlighted the value of real-time engagement between CDS staff and treating clinicians. This interaction was critical to improving documentation quality and became a foundational element of e-ITL.
The shift to a digital workflow addressed limitations in CDS resourcing by enabling the team to expand its reach across multiple specialties without requiring proportional increases in staff. The main distinction between the two models lies in leveraging the capabilities of the electronic medical record: e-ITL uses digital systems to extend the reach of the CDS team, enabling ‘virtual’ ward rounds and facilitating documentation queries and responses directly within the digital record, rather than relying on verbal interactions during physical ward rounds as in the original ITL approach.
Given the significant size and scope of the health service, and limited CDS resources, it was necessary to develop a strategy for prioritising efforts. The team uses a data-driven approach to identify specialties where the most value can be realised. An integral part of this strategy involves comparing DRG complexity distributions at Gold Coast Health with those of previous years and against peer hospitals. Specifically, the CDS team assesses the proportion of ‘major complexity’ discharges across different specialties. While various factors can influence complexity distribution, specialties with fewer major complexity cases than expected may reflect under-documentation. For example, if benchmarking reveals a lower-than-expected percentage of major complexity DRGs in a particular specialty, this can act as a trigger to assess whether there are opportunities to improve the capture of clinical complexity in documentation.
In addition to benchmarking, some retrospective audits are used to support the concurrent review process by evaluating the accuracy and completeness of documentation—particularly when targeting documentation improvement and complexity uplift. The patient cohort identified for daily concurrent review is generated from a new locally developed PowerApps application, ‘Query Canvas’. The dataset provides a list of patients, focusing on acute inpatient admissions in target specialties such as Orthopaedics, Vascular Surgery, Stroke, and General Surgery (including subspecialties like Colorectal Surgery, Hepatopancreatobiliary Surgery, Acute Surgical Unit, and Upper Gastrointestinal Surgery). Patients are selected for review based on a length of stay between two and eight days. The rationale is that patients discharged within two days are less likely to have complex care requiring CDS input, while patients staying beyond eight days have usually been reviewed or are receiving prolonged care due to established complexity.
After identification of target specialties, engagement with clinical leadership occurs to ensure collaboration and communication of shared expectations and outcomes. These discussions focus on the potential benefits of improved clinical documentation, such as increased funding and more accurate representation of patient care. Department leaders then collaborate with health information leadership and the CDS team to develop implementation plans that define clinical documentation processes, set clear expectations, and establish open lines of communication. Maintaining clinical engagement over time is crucial, especially with the regular rotation of junior doctors. To support continuity, CDS team members work with clinical leads to orient new doctors to documentation expectations and ensure consistency in practice.
Education remains a key pillar of the CDS service but is primarily focused on those clinicians most engaged with the real-time process—namely junior medical officers and registrars. The ‘Nail Your Notes’ program includes orientation sessions for interns, Junior House Officers, and Senior House Officers, providing foundational knowledge of documentation principles, common pitfalls, and guidance on responding to queries within the integrated electronic medical record (ieMR). Principal House Officers and registrars are supported with more advanced content, including how to capture clinical complexity and link diagnoses to clinical care, as well as a foundational understanding of clinical coding and activity based funding (ABF).
Specialty-specific and ad hoc education sessions are offered, addressing the unique documentation challenges of each specialty. The team also provides targeted education for International Medical Graduates, and Griffith University medical students—particularly those in the scribe program.
The outcomes of e-ITL queries are routinely analysed to assess their impact on ABF, clinical coding accuracy, and complexity capture. These insights help shape specialty targeting, educational focus, and engagement strategies. The CDS team also works with clinical coding liaisons to ensure a shared understanding of clinical documentation requirements and to present findings to Clinical Coders during quarterly education days.
Because the CDS team interacts with clinical documentation while care is in progress, their activities contribute to safer, more timely communication. The use of the ieMR ensures all queries and responses are recorded and traceable, supporting the health service’s compliance with national safety and quality standards.
One of the challenges encountered during implementation has been occasional delays in clinician response to documentation queries, particularly in the early stages of engagement in newly targeted specialties. In most established areas, clinician response rates have been high and consistent, reflecting strong buy-in and integration of the CDS process. However, as new specialties come on board, competing clinical demands and unfamiliarity with the process can temporarily affect response times. To support consistency, the CDS team works closely with clinical leadership to orient new staff and reinforce expectations.
To help ensure queries are actioned, a tiered follow-up and escalation process has been implemented. CDSs typically follow up with the responsible medical officer after two days in most areas, and after five days in General Surgery. If no response is received, escalation to the consultant or senior medical officer generally occurs after seven days, or ten days in the case of General Surgery. While these timeframes provide a general guide, they are applied with flexibility depending on clinical circumstances. This structured yet adaptive approach helps maintain momentum and supports timely resolution of documentation queries.
The implementation of e-ITL has created a responsive and effective feedback loop for medical officers responsible for clinical documentation. It enables prompt, hands-on application of best-practice guidance, offers real-time feedback opportunities while patients are still admitted, and allows clinicians to observe the impact of their documentation improvements within the same admission.
By embedding this process within the electronic medical record, e-ITL has enhanced the overall reliability and accuracy of clinical documentation. It supports precise clinical code assignment, improves interdisciplinary communication, and ensures that the rationale for treatment decisions is clearly captured. These improvements contribute not only to safer patient care but also to clearer clinical records and more consistent data quality. In some instances, documentation queries have also served as helpful clinical prompts. For example, following a query related to low haemoglobin, a medical officer advised that it prompted them to recognise the need for—and subsequently administer—an iron infusion. This feedback illustrates the broader benefit of the CDS model, not only in improving documentation accuracy but also in reinforcing clinical decision-making and patient care.
The proactive nature of the CDS model has also been particularly valuable in supporting junior medical officers. It has contributed to faster response times to documentation queries, greater adoption of documentation best practices, and improved clinical coding integrity. In turn, this supports more accurate reflection of patient complexity and resource use.
The Gold Coast Health Optimisation team has also benefited from strong support by clinical leadership, as well as the Funding Innovation Committee—a dedicated group of departmental managers and executives who assist in addressing concerns related to ABF throughput. This organisational backing has been instrumental in enabling the CDS program to expand into additional specialties, supporting more effective and sustainable implementation across the health service. Notably, improved documentation has contributed to increased ABF returns, ensuring reimbursement more accurately reflects the true complexity of the patients we care for.
In the 2024 financial year alone, the CDS team reviewed over 4,500 patient admissions, issued 2,450 documentation queries, and generated approximately $6.15 million in recovered revenue through improved capture of clinical complexity.
Gold Coast Health intends to continue developing the CDS program with a range of strategic goals aimed at strengthening and expanding its impact. Planned initiatives include:
These initiatives aim to build on the strong foundations of the current program, ensuring that documentation continues to reflect the complexity and quality of care delivered while enhancing clinician capability and engagement across the organisation.
Shannon Sumner, BSc(HIM)
Optimisation Manager, Health Information; Gold Coast Health
GCUH, 1 Hospital Boulevard
Southport QLD 4215
Tel: (07) 5687 3825
Email: shannon.sumner@health.qld.gov.au
Dr. Joevin Vincent, MBBS, MAHSM
Clinical Documentation Specialist; Gold Coast Health
Roxanne Carroll, DipAppSc(Nursing)(Hons), BA(Psych), MACL(Clinical Leadership)
Clinical Nurse Consultant – Clinical Documentation Specialist; Gold Coast Health
Sacha Acworth, BNurs
Registered Nurse & Clinical Documentation Specialist; Gold Coast Health
Emma White, BNurs, BExSc
Registered Nurse & Clinical Documentation Specialist; Gold Coast Health
Vinod Sati, BHlthSci(Physio), GradCert(SportExSci)
Clinical Documentation Specialist; Gold Coast Health
Originally published by the Health Information Management - Interchange (HIM-I).