Clinical Documentation Improvement Tips

Tips for Improving Your CDI

Excessive Note Taking = Less Reviews = Decreased Productivity

by Kelli Estes, RN, CCDS on

Kelli Estes, RN, CCDS

CDI Review Notes – How much is too much?

Compiling a “CDI version” of the documented H & P is too much!

Inevitably, CDSs need to make notes to prompt their thoughts about the cases they review, but there is much better use of time and productivity by honing in on what lacks in documentation rather than copying what is already well stated.

In defense of a CDS “newbie”, writing down more clinical content in the review notes is understandable and certainly expected while training. However, as the CDS matures, irrelevant content will become much clearer thus resulting in less daily review notes.

The CDS must gain perspective regarding the intent of review notes. The logic behind review notes is to assist any CDS with being more efficient in their work not a burdensome process eating away excessive amounts of time. In reality, CDI review notes are intended to serve as a quick reference to the potential need for pursuing improved documentation via physician clarifications.

It is important to note that the vast majority of CDSs entering the marketplace are nurses. Nurses are trained to give and receive shift reports encompassing a thorough overview of the patient’s active medical problems as well as past medical history, treatments, labs, x-rays, diet, activity, etc. This is part of a process embedded into the standard training for nurses. As a nurse, it is difficult to embrace different methods of note taking as it relates to the world of CDI. Like any learned process, it is difficult to make changes.

Additionally, nurses are not coders. However, they need a “working knowledge” of coding to do their job well. Because of this, they sometimes feel the need to write more than what’s necessary. It helps to have a strong “working knowledge” of coding to understand how certain type notes will help compliment their work when identifying the need to obtain more specific physician documentation.

But, in the end, it would be most helpful to just keep it simple and review more cases!

R & R… Sometimes it’s necessary!

by Kelli Estes, RN, CCDS on

Kelli Estes, RN, CCDS

Though rest and relaxation sounds inviting, in the world of CDI (clinical documentation improvement) R & R helps clear up any uncertainty as to what the clinical picture is presenting. Conditions ruled-out or stated as resolved go a long way in helping coders more accurately assign the right ICD-9 codes resulting in the proper MS-DRG assignment.

According to the term ruled-out means to eliminate or exclude something from consideration.

We need to advocate clarifications from the CDI staff to the medical staff for the purpose of R & R.

Understandably, physicians may not be certain about specific diagnostic conditions initially so they use terms like “probable”, “likely”, “possible”, “suspected”, “to be ruled-out”, or “questionable” while work-up is under way. Conditions NOT carried through in the documentation to the final progress note or discharge summary could benefit from CDI intervention to help determine if said conditions were either ruled-out or resolved.

For example:

Is the documented “possible” Sepsis ruled-out or was the sepsis treated and now it is resolved?

Chest pain is documented as “probably due to the patient’s GERD”. This is charted in the H & P as well as the progress notes on day 1 and 2 of the stay. On day 3, the diagnosis is listed as chest pain and the probable cause is never mentioned again. Was the GERD ruled in or ruled out as the cause of chest pain?

Obtaining clarification for conditions “ruled-out” or “resolved” when applicable will also help remove the burden of confusion befalling the coder. If a condition is present and being treated as such then it should be consistently carried through in the documentation of the medical record. Otherwise, physicians should document “ruled-out’ or “resolved” to help paint the proper clinical picture with their words.

Let’s make sure we get proper R & R!

Working from a Closet is NOT such a Good Idea!

by Kelli Estes, RN, CCDS on

Kelli Estes, RN, CCDS

As the EMR (electronic medical record) makes its way into more and more hospitals, the challenge for CDSs (clinical documentation specialists) staying engaged with the medical staff is certainly on the rise.

What we are seeing in hospitals with a full EMR is the tendency of CDSs to navigate toward a “closet” space to review inpatient records.

It starts out as a potentially viable process in facilities using hybrid records. Let’s face it; real estate in a hospital is always in short supply! CDSs review the EMR portion from the office and then go to the patient care units to finish up their reviews. Using this model of review, CDSs are still on the units to some degree. Though reviewing hybrid records in this way does not facilitate an efficient use of time. It is best to be on the units so both EMR and paper portions of the record can be available for completion to include any needed physician clarifications.

Once the full EMR goes live, CDSs are settled into their offices and it becomes very “easy” to stay in the office for reviews and issue electronic queries/clarifications right from the comfort of their own “home”.

Seems harmless enough. Not so fast!

There is simply NO substitute for having CDSs work from the patient care units!

The following examples highlight some of the reasons it is important to maintain CDSs on patient care units:

CDSs are perceived as part of the team when on the patient units
CDSs start to earn the respect as a valid resource readily available to the medical staff
Available to jump in on rounding opportunities
CDSs remain in ear shot of conversations among providers allowing for opportunities to interject documentation tips when appropriate
Verbal clarification opportunities will have a significant increase resulting in a better response rate from physicians
The presence of CDI staff on the units serves as a reminder to those around to be cognizant of CDI

Just because you CAN access the EMR from a “closet office” off the unit certainly does NOT mean you should!

Hypotension vs Shock

by Randy Wagner, BSN, RN, CCS on

Randy Wagner, BSN, RN, CCS

67 y.o. male was admitted with a hip fracture and it was decided to do a hip replacement. Intra-operatively the femur bled and the patient lost about 1000 ml of blood. Overnight the patient’s blood pressure, baseline 130s/90s, dropped to 80s/40’s. Heart rate, baseline high 60s & low 70s, increased to 90s & 100s. Hgb on admission was 14 which dropped to 8.2 post-op.

Treatment with vasopressors followed by 500ml/hour until vital signs improved. Placed on 10L O2 & non-rebreather initially and once vital signs stable decreased to 3-4L, Patient was continually monitored in ICU, taking 10 hours to recover.

Documentation stated hypotensive due to 1000ml blood loss.

The CDS wrote a clarification, addressing it to both the surgeon and hospitalist, asking if the event was Hypovolemic Shock, with or without Anemia due to Acute Blood Loss or was the hypotension due to some other etiology.

The surgeon documented in his next note that the patient’s episode was due to Hypovolemic Shock and the Hospitalist documented Anemia due to Acute Blood Loss.

Previous Encounters

by Kelli Estes, RN, CCDS on

Kelli Estes, RN, CCDS

Using previous encounters to glean helpful information when clarifying patient conditions is often misunderstood. Some CDSs are of the mindset any information from a prior encounter is off limits when trying to clarify conditions in a current stay.

I suspect this line of thinking has been established from the following AHIMA practice brief.

Managing an Effective Query Process:


From the Official Guidelines for Coding and Reporting:


After reading these excerpts from the practice brief as well as the guideline for coding and reporting, you have to consider the logical intent of the guidance given.

In the current case, the patient is still on antibiotics for the cellulitis that was identified on a previous hospital stay. Official coding guidelines state that this MUST be coded as the event in the absence of codes for chronic care as exists with pulmonary embolism.  To not provide a diagnosis to justify ongoing treatment with the antibiotics negates all reason for demonstrating medicine reconciliation and meaningful use.

The universally promoted concept of “Meaningful Use” means that the treating team must be aware of all elements of a patient’s health status in order to ensure that proper care is rendered, interaction after interaction.  The concept of “unified health record” means that all aspects of a patient’s holistic care regimen is to be directed by knowledge of all of the elements of a patient’s health status.

CKD (Chronic Kidney Disease) Staging example:

CKD staging is determined by the patient’s stable GFR (glomeruler filtration rate). Often physicians document AKI (acute kidney injury) on CKD. Staging of CKD is often missing in the documentation, but the diagnosis of CKD is well established as a chronic condition requiring evaluation and management. With the advent of EMR (electronic medical record), it makes sense to assess the trend in GFRs over time when that information is accessible. The whole point to an EMR is for providers to be able to have more complete information across the continuum of care. It is doing the patient an injustice when CDSs do not ask physicians to consider being more specific with the staging of CKD when baseline GFRs are available for consideration in the EMR from prior hospitalizations and in some cases clinic notes. Otherwise, it would be impossible for a physician to determine the CKD staging for a patient in AKI. When writing a clarification to the provider, it is important to clearly state where you obtained any baseline information.

For example, my concurrent clarification might look something like the following:

Dr. Smith,
Patient admitted 7/16 with AKI on CKD. Admitting creatinine level = 3.2, BUN 55 (GFR 19). 7/17 creatinine improved to 2.8 and BUN 46 (GFR 22). Noted patients GFRs during the last 6 months to range from 35 – 59. As this patient continues to improve toward baseline, can you please determine the CKD stage for this patient and document in your progress notes once established?

See GFR staging table below.


The knowledge of a patient’s CKD status is dependent on knowledge of historical data.  To ignore this is inappropriate.

CO2 Narcosis

by Randy Wagner, BSN, RN, CCS on

Randy Wagner, BSN, RN, CCS

Patient was intubated and moved to ICU yesterday. Diagnosis in the note “ventilator dependent rest. Failure secondary to acute COPD exacerbation and altered mental status secondary to CO2 narcosis”.
Am I correct in thinking that he would still need to say acute for the respiratory failure?

Yes, Clarify if the patient was in Acute on Chronic Respiratory Failure. If the patient does not recover quickly, then it would also be appropriate to clarify if the altered mental status was an indicator of metabolic encepholopathy.

CO2 narcosis happens when people are given too much oxygen which slows down the oxygen driven drive . Then CO2 can build up (hypercapnea) and reach levels that can be toxic and can be lethal.

Patients with acute respiratory failure or exacerbations of chronic respiratory failure need to be admitted to the intensive care unit for ventilatory support. Patients generally are prescribed bed rest during early phases of respiratory failure management.

Capturing Nutritional Issues Initiative: A Collaborative Effort

by Cesar Limjoco, MD on

Cesar Limjoco, MD

In the past, Clinical Documentation Specialists (CDS) would ask the provider if the patient had nutritional issues based on evidence in the history, physical exam findings and lab results. They would rely on history of weight loss, findings of emaciation and body wasting, BMI, protein, albumin to ask the provider if the patient had malnutrition and its severity. Hearsay, incorrect BMIs recorded because of faulty information, abnormal losses of protein from non-nutritional issues have led to incorrect documentation of malnutrition by providers. Medicare and RAC auditors have targeted inappropriate coding of malnutrition, in cases that it is the only CC or MCC.

Dietitians have bristled at the amount of malnutrition that has been recorded by providers inappropriately. Nutritional expertise truly resides in the dietitian’s domain. They can weed out weight loss hearsay, confirm accurate BMIs, and have more accurate determination of patients’ nutritional issues. But, they are not allowed to make the diagnosis because only the providers are licensed to make the diagnosis.

In 2012, parameters for evaluation and stratification of malnutrition by nutritionists were changed. BMI, protein and albumin parameters were taken out from the criteria in identifying malnutrition. Caloric intake, weight loss and duration, physical assessment findings of subcutaneous fat loss, muscle mass loss, fluid accumulation and reduced grip strength have become the primary parameters. Thus, making it even more difficult and confusing. Most providers are reluctant to call the diagnosis without the dietitian’s full assessment.

This leads to a catch-22 situation. The providers who are licensed to make the diagnosis do not feel they have the expertise. The dietitians who have the expertise are not allowed to make the diagnosis. The solution lies in a collaborative effort between the providers, dietitians, floor nurses, CDS, and even Wound Care RNs, PT and Pharmacy. All these folks have a stake in the capture of nutritional issues.

Since the dietitians are not able to cover all patients that are admitted to acute inpatient care, they need a good referral system from all the stakeholders. The floor nurse fills out a nutritional screening form for all patients admitted to inpatient care. CDS, Wound Care RNs, PT and Pharmacy can also refer patients directly to dietitians.

New policies and procedures for the dietitians have to be formulated to assess and make a determination of patients’ nutritional issues and their severity (mild, moderate, severe). They have to go through their own Nutrition committee and have the Medical Executive committee approve and authorize the initiative. Since physical assessments have not been traditionally part of their training, they need to be trained by Rehabilitation Medicine providers or PT to make the physical assessments (i.e., SQ fat loss, muscle mass loss, fluid accumulation, reduced grip strength).

It takes time for new policies and procedures to be approved. An interim agreement for dietitian referral needs to be established. Otherwise, some dietitians may not be willing to go outside their regular scope of work and comfort level. Gray areas can be resolved by full dietary team consultation.

All of the above can only be undertaken with the cooperation of the dietary department. A preliminary meeting with the clinical manager of the dietary department would be the first step, which leads to a discussion of the need for their cooperation in starting an initiative. Showing how nutritional issues affect clinical outcomes as well as its financial impact may help convince the need for such an undertaking. Administration support for this initiative is critical.


Case of Late Stage Non-Alcoholic Cirrhosis

by Randy Wagner, BSN, RN, CCS on

Randy Wagner, BSN, RN, CCS

Emergency Deptartment impression states “Altered mental Status.” H&P states that upon exam the patient was “foggy”. Lab data shows ammonia level to be elevated. After treatment the ammonia level markedly decreased and the patient’s mental status returned to baseline.

The CDS should clarify if “altered mental status” and “foggy” were indicators for Encephalopathy and if so, was it Hepatic or some other etiology?

Working in Silos is Never a Good Idea

by Randy Wagner, BSN, RN, CCS on

Randy Wagner, BSN, RN, CCS

The hospital has an electronic medical record system.  Management of the clinical documentation team originally decided to send physician clarifications via email.  The response rate from the physicians was poor.  CDS management decided to meet with the physicians and get their opinions as to how to send clarifications.  The physicians suggested using the message center in the EMR.   This allows the physician to see the clarification in the patients medical record thus making it much more convenient to answer.

So, working with the physicians to determine the best process for clarifications will result in an improved response rate.

Acute Respiratory Failure

by Timothy Shulte, MD on

Kelli Estes, RN, CCDS

Appropriate use of the term “acute respiratory failure” has become a hot topic recently. Some well-meaning CDSs, billers and doctors have fallen into the trap of using the term in order to bill at a higher level. This is an especially timely topic with the advent of Value Based Purchasing. At a recent client site, the pulmonary intensivists were using the term 100% of the time in their post procedure patients on a ventilator. I met with these doctors the next morning during rounds. We saw 4 patients, three of which had no problems being weaned off the vent using standing orders. The fourth patient arrested during the night after being weaned from the ventilator and had to be re-intubated. The time the intensivists spent with the first three patients was very brief. The decision making and time spent with the fourth patient was obviously more intense. It was clear that the fourth patient had indeed had an episode of acute respiratory failure. The ventilator management of the other three patients was just an integral part of the procedure and therefore use of the term “acute respiratory failure” would be inappropriate. Rounding with these doctors was incredibly beneficial. This is a very effective way to resolve documentation issues; reviewing their patients’ charts in real time.