![]() ![]() Let me give you some pointers to ward off queries. You are not being asked for more documentation by the CDI team they are entreating you for higher-quality documentation. But the goal isn’t to torture the physician – it is to ensure that the medical record is accurately depicting the encounter. From this explanation, you might well conclude that the CDI specialist could generate a query on every patient if they were so inclined, and you would be correct. They are charged with getting practitioners to associate clinical indicators with diagnoses and to consider removal of diagnoses which do not seem clinically valid from the existing documentation. Many hospitals now have a clinical documentation integrity (CDI) team which is tasked with querying the provider when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent. The advent of the electronic medical record was just the straw that broke the camel’s back. Having clinical documentation serve too many masters, including compliance, quality, medicolegal, utilization review, and reimbursement, is also to blame. Getting no training on how to properly document in medical school/residency and receiving no formative feedback on documentation throughout one’s career compounds the problem. Having clinicians jump through regulatory hoops which do not advance patients’ care, and providers misunderstanding the requirements for level-of-service billing are the essential issues. Documentation isn’t fundamentally the problem. ![]() The solution is flawed (that is, future relaxation of documentation requirements for professional billing) because the premise is delusive. The Centers for Medicare & Medicaid Services is touting its “Patients over Paperwork” initiative. The chronological storytelling and trustworthiness of the medical record has become suspect. Prepopulation of templated notes, defaults without edit, and dictation without revision have degraded our documentation to the point of unintelligibility. In the current electronic records environment, we are inundated with excessive and repetitious information, data without interpretation, differentials without diagnoses. The discharge summary then encapsulated the hospitalization in several coherent paragraphs. The chart told the patient’s story, hopefully legibly and without excessive rehashing of previous material. The medical record was a chronological itemization of the encounter.
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