ACDIS update: New white paper examines how to review a medical record

CDI Strategies - Volume 12, Issue 51

Medical record review is a core CDI responsibility. According to the 2016 ACDIS CDI Productivity Survey, CDI specialists review an average of 16–24 patient charts daily, a task that compromises the bulk of their workday.

During the review, CDI professionals comb the chart for incomplete, imprecise, illegible, conflicting, or absent documentation of diagnoses, procedures, and treatments, as well as supporting clinical indicators. Their goal is to cultivate a medical record that stands alone as an accurate story of a patient encounter, providing a full picture of the patient’s illness and record of treatment. A complete record allows for continuity of care, reliable collection of mortality and morbidity data, quality statistics, and accurate reimbursement.

To help CDI professionals in this central piece of their work, the ACDIS Advisory Board has published a new white paper titled “How to conduct a medical record review.” The paper defines a recommended process for medical record review. This includes the important first step of defining the “why” behind the review, and marrying the review outcome to organizational goals.

The paper also describes a recommended step-by-step review process, starting with emergency department documentation and continuing to the history and physical, progress notes, and query and follow-up. This paper defines, and differentiates, initial and subsequent reviews and offers suggestions for capturing not just physicians’ critical thinking, but that of the CDI specialists, too. It also discusses reconciliation of coded data, advanced chart review techniques, and the present state of assistive technology.

ACDIS administration and the Advisory Board hope you find this new paper beneficial. Click here to read the paper in its entirety.