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:
- Ensure that all clinical documentation accurately reflects the care and treatment provided to patients, promoting patient safety and quality of care.
- Support accurate coding and billing practices, ensuring appropriate reimbursement and financial sustainability for the hospital.
- Maintain data integrity by ensuring complete and consistent documentation, facilitating accurate capture of patients’ complexity and casemix.
- Facilitate effective communication among healthcare professionals involved in patient care.
- Address documentation queries in a timely manner to support accurate coding and reimbursement.
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.
Definitions:
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:
- Commencement, alteration or adjustment of treatment
- Diagnostic procedures, or
- Increased clinical care.
Policy Guidelines:
Documentation Standards:
- All healthcare providers are responsible for maintaining accurate, comprehensive, and legible documentation in the patient's medical record.
- Documentation should adhere to the hospital's established guidelines, which may include the use of templates, forms within the medical record.
- Documentation should reflect the patient's condition, treatment, response to therapy, and any changes in their clinical status.
- Healthcare providers should document their observations, assessments, diagnosis/es, interventions, and outcomes in a timely manner.
Query Process:
- Clinical Documentation Specialists or coding staff may raise queries when performing concurrent reviews and identify documentation is unclear, incomplete, or inconsistent.
- Queries will be directed to the responsible healthcare provider within their scope of practice, for clarification or additional information.
- Documentation queries must be answered within 72 hours of receipt.
- Healthcare providers are responsible for reviewing and responding to queries promptly and thoroughly.
- The response to a query should be entered as an addendum to the original progress note or in a separate addendum section as appropriate in the medical record.
- The addendum should clearly reference the query and provide a detailed response that clarifies or supplements the original documentation.
- If the healthcare provider determines that no further information is necessary or that the original documentation is correct, this should be clearly stated in the response.
- In cases where the healthcare provider cannot answer the query within the 72-hour timeframe, they should communicate this to the Clinical Documentation Specialist or coding staff, providing an estimated timeline for completion.
Responsibilities:
Healthcare Providers:
- Ensure accurate, complete, and timely documentation of patient information.
- Review and respond to documentation queries within 72 hours.
- Seek guidance from Clinical Documentation Specialists or coding staff if unsure about how to respond to a query.
- Participate in training and education programs to improve clinical documentation knowledge and skills.
Clinical Documentation Specialists:
- Perform concurrent reviews of patient episodes, review clinical documentation to identify gaps in documentation relating to the principal diagnosis or additional diagnosis/es.
- Raise queries when necessary to clarify diagnosis/es are missed, unspecific, or not clearly linked to treatment.
- Communicate query responses to coding staff or relevant personnel.
- Provide education and support to healthcare providers regarding clinical documentation practices promoting “due to” and “be specific” messages.
Coding Staff:
- Collaborate with Clinical Documentation Specialists to identify potential documentation gaps or ambiguities.
- Assign accurate and appropriate codes based on the available documentation.
- Communicate with healthcare providers regarding coding-related questions or query responses.
Compliance and Monitoring: Compliance with this policy will be monitored through regular audits of clinical documentation and query responses.
Escalation Process
- If a documentation query has not been answered within 72 hours, a first reminder will be sent to the responsible healthcare provider by the Clinical Documentation Specialist or coding staff.
- If the query remains unanswered after the first reminder, a second reminder will be sent to the responsible healthcare provider 48 hours after the first reminder.
- If the queries are not answered repeatedly by the same healthcare provider, escalation is necessary to ensure timely resolution.
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.
Compliance Rate:
- The hospital aims to achieve a 100% compliance rate in terms of documentation query response within the stipulated 72-hour timeframe.
- Continuous monitoring, auditing, and feedback mechanisms will be implemented to identify areas for improvement and ensure consistent adherence to the policy.
- Education and training programs will be provided to healthcare providers to enhance their understanding of the importance of timely query response and the impact on patient safety, data integrity, financial sustainability, and regulatory compliance.
References:
Independent Health and Aged Care Pricing Authority. Australian Coding Standards. 12th Edition. July 2020.
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