The Importance of CDI Review Notes

Clinical Documentation Improvement (CDI) review notes play a critical role in ensuring the accuracy and integrity of patient medical records. These notes capture the thought processes of CDI specialists, documenting their findings, queries, and any necessary follow-ups. CDI review notes facilitate effective communication between CDI specialists, coding professionals, and healthcare providers by clearly outlining the rationale behind coding decisions and any discrepancies found in the medical record.

Accurate CDI review notes help maintain consistency in documentation, ensuring that the medical record accurately reflects a patient’s conditions and treatments. This accuracy is crucial for proper reimbursement, quality reporting, and patient care continuity. Additionally, well-documented review notes support the reconciliation of CDI findings with final coded data, ensuring that critical diagnoses are correctly represented.

• Critical Thinking: CDI review notes capture the essential thought processes of CDI specialists, helping other team members understand the approach taken.
• Consistency and Accuracy: These notes ensure that patient records accurately reflect all conditions and treatments, which is essential for correct coding and quality care.
• Effective Communication: CDI review notes foster collaboration between different healthcare professionals, reducing the chances of rework and ensuring a unified approach to patient care.

These notes contribute to the overall quality and integrity of patient records by providing a clear and concise record of the CDI process, supporting better patient outcomes and operational efficiency in healthcare settings.

What Does an Effective CDI Review Note Look Like?

An effective Clinical Documentation Improvement (CDI) review note is structured and detailed and serves as a comprehensive record of the review process. It ensures that all relevant information is captured, discrepancies are noted, and plans for follow-up are clearly outlined. Here’s what makes a CDI review note effective, including essential items to address during initial, continued, and retrospective reviews.

Critical Elements of an Effective CDI Review Note:

Initial Review:

1. Chief Complaint/Reason for Presentation: Document the patient’s chief complaint, including signs and symptoms, initial impressions, and whether the patient was in observation status or admitted for inpatient care.
2. Principal Diagnosis: Clearly state the principal diagnosis and assess for opportunities for change. Note any pending tests that could impact the diagnosis.
3. CC/MCCs Validation: Validate any CC/MCCs by supporting them with relevant clinical indicators such as lab results or diagnostic findings.
4. Query Opportunities: Document any query opportunities, providing reasoning if a query was not sent.
5. Significant Findings: Note any significant findings that are not directly related to the principal diagnosis or CC/MCCs, including vital signs, lab results, and ancillary notes.
6. PSI/HAC Findings: Identify any Patient Safety Indicators (PSI) or Hospital-Acquired Conditions (HAC), commenting on exclusion criteria and present on admission status where applicable.
7. Focus of Next Review: Outline what you will be questioning or watching for in the following review.

Continued Review:

1. Review Principal Diagnosis: Reassess the principal diagnosis to determine if it remains solid or if there are new opportunities for adjustment.
2. New CC/MCCs Validation: Validate any new CC/MCCs with supporting clinical indicators.
3. New Query Opportunities: Identify new query opportunities and provide reasoning if a query was not sent.
4. New Significant Findings: Document any new significant findings, such as changes in vital signs or lab results, that are not directly related to the principal diagnosis.
5. New PSI/HAC Findings: Identify any new PSI/HAC findings, comment on any exclusion criteria, or present on admission status.
6. Focus of Next Review: Plan what you will focus on in the subsequent review, noting any questions or areas to monitor.

Retrospective Review:

1. Reason for Review: Specify the reason for the retrospective review, such as hospice/mortality, PSI, clinical validity, or query response.
2. Outcome of Review: Summarize the outcome of the review, addressing key findings and actions taken.
3. Hospice/Mortality: If applicable, document any query opportunities not sent and explain why. Consider escalating to a physician advisor if a query receives an unexpected response.
4. PSI/HAC: Comment on exclusion criteria and present on admission status for any PSI/HAC findings.
5. Clinical Validity: Provide indicators that support the diagnosis or send a query if necessary.
6. Query Response: Address any unexpected or inadequate responses to queries and consider escalating for educational purposes if needed.

Example of an Effective CDI Review Note:

Date of Review: August 5, 2024

Reviewed by: Jane Doe, CDI Specialist

Initial Review:

• Chief Complaint/Reason for Presentation: The patient presented with shortness of breath and chest pain, initially observed in the ED for potential myocardial infarction before being admitted for inpatient care.
• Principal Diagnosis: Aspiration Pneumonia (J69.0) was identified in the progress notes and discharge summary. The sputum culture results are pending to confirm the pathogen.
• CC/MCCs Validation: Acute Tubular Necrosis (N17.0) was validated by a rise in creatinine levels from 1.6 to 3.5 post-contrast administration.
• Query Opportunities: A query was considered for sepsis diagnosis due to inconsistent documentation but was not sent pending further clinical validation.
• Significant Findings: Initial labs show elevated white blood cell count and abnormal chest X-ray. Vital signs indicate tachycardia and hypotension.
• PSI/HAC Findings: A pressure ulcer on the left hip was noted on admission. No exclusion criteria were identified.
• Focus of Next Review: Monitor sputum culture results and re-evaluate sepsis documentation. Follow up on the response to initial treatments.

Continued Review:

• Principal Diagnosis: Principal diagnosis remains solid with no new opportunities for change.
• New CC/MCCs Validation: In subsequent labs, no new CC/MCCs were identified.
• New Query Opportunities: There is a new opportunity to query for malnutrition based on weight loss and albumin levels, but the query has not been sent pending the dietitian’s assessment.
• New Significant Findings: The patient’s blood pressure stabilized, and oxygen saturation improved with continued monitoring.
• New PSI/HAC Findings: No new PSI/HAC findings were identified.
• Focus of Next Review: Monitor nutritional status and follow up on pending diagnostic tests.

Retrospective Review:

• Reason for Review: A retrospective review was conducted due to the patient’s unexpected transfer to hospice care.
• Outcome of Review: No additional queries were identified. Documentation supported the transition to hospice care.
• Hospice/Mortality: No new query opportunities were identified. Documentation of palliative care and DNR status was appropriate.
• PSI/HAC: No PSI/HAC exclusion criteria issues were noted.
• Clinical Validity: Diagnoses confirmed with clinical indicators; no further queries are needed.
• Query Response: All query responses were adequate and did not require escalation.

Why It Matters

Practical CDI review notes ensure that all relevant clinical information is accurately captured and documented, supporting better patient care and providing appropriate coding and reimbursement. By including all the necessary elements in a structured format, CDI specialists contribute to maintaining the integrity of the medical record, ultimately leading to improved healthcare outcomes.