Maintaining Clinical Documentation Integrity during Hospital Restarts

Clinical Documentation Integrity (CDI) team members must support physicians through the query process, as provider focus has shifted to COVID-19. Continuing to query for comprehensive documentation in the medical record is vital and will ensure complete and accurate accounting of the patient’s disease processes and complexity of care.

The CDI team must prioritize cases where accurate documentation is necessary. At the time of discharge, the inpatient coder assigns ICD-10 codes for diagnoses and procedures documented in the medical record. If there is vague, incomplete, or conflicting documentation in the record at discharge, coding and billing could be delayed until physician documentation is complete. The purpose of CDI is to work with physicians while the patient is hospitalized to confirm physician documentation is specific, accurate, and complete.