Purpose of this document
This document aims to provide guidance to healthcare services in establishing an internal policy to support their clinical documentation improvement (CDI) program. It is intended as a reference and may be adapted as required.
As part of the CDIA Pursuit Program, CDIA is available and willing to assist during any stage of policy development, including content review.
Consideration for healthcare services
When drafting a CDI policy document, the CDI team should take into account any existing documentation policies. This consideration should encompass variations that may exist due to the use of electronic medical records and paper records.
The reporting line for Clinical Documentation Specialists (CDS) may vary depending on the size and organisational structure of your health service. In some hospitals, the CDS may report to the CFO/Finance Manager, while in others, they may report to the DON/DMS or the HIS Director/Chief HIM. The ultimate decision on reporting structure is made to best suit your organisation. CDIA recommends that the CDSs report through a clinical reporting line e.g. a DON or DMS. Such a reporting structure will ensure the role maintains a patient safety and quality focus, continuing to empower your clinicians to deliver safer care to every patient.
Query processes can differ between healthcare services due to variables such as electronic medical records, paper records, and the structure of your health service. Ensure that this document provides clear instructions on how the CDI team raises queries and the most effective way to obtain responses in consultation with the clinical coding team.
The CDS role is largely self-directed and thus requires individuals with significant personal initiative. Engaging with clinicians is commonly the most challenging aspect of the role. Therefore, it is essential to set expectations for when to receive query responses from clinicians and establish escalation processes in case queries are frequently left unanswered.
Example CDI policy
Policy Title: Clinical Documentation Improvement and Query Response Policy.
Policy Statement: This policy establishes guidelines for clinical documentation within the hospital to ensure accurate, complete, and timely recording of patient information. It also outlines the process for responding to documentation queries raised by Clinical Documentation Specialists or coding staff.
Purpose: The purpose of this policy is to:
Scope: This policy applies to all healthcare providers, including doctors, nurses, allied health professionals, and any other personnel involved in documenting patient information within the hospital setting.
Clinical Documentation Specialist (CDS): A qualified healthcare professional responsible for analysing and improving the quality of clinical documentation within the hospital.
Documentation Query: A written, electronic, or verbal request for additional information or clarification regarding the documentation in a patient's medical record.
Principal Diagnosis: The diagnosis established after study to be chiefly responsible for occasioning the patient's episode of care in hospital.
Additional Diagnoses: Conditions that significantly affect patient management in an episode of care in terms of requiring any of the following:
Clinical Documentation Specialists:
Compliance and Monitoring: Compliance with this policy will be monitored through regular audits of clinical documentation and query responses.
In the case of unresolved queries, the matter will be escalated to the specialty senior clinician, the Executive Director of Medical Services (EDMS), or the CDI Champion designated for the respective department or specialty.
The specialty senior clinician, EDMS, or the designated CDI champion will actively engage with the healthcare provider to facilitate the resolution of the query and ensure compliance with the policy.
Independent Health and Aged Care Pricing Authority. Australian Coding Standards. 12th Edition. July 2020.
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