ACDIS update: Record review case study white paper published
When the CDI team at Legacy Health System (LHS) in Portland, Oregon, began to develop a record review process and documentation standards, they quickly discovered that there were no clear formal industry standards. In an effort to streamline and standardize the CDI review and documentation process, LHS undertook a long process of evaluation, modification, and reassessment, eventually arriving at a template and process that worked for them.
Their work helped identify data by which LHS can show improvement in key areas of CDI documentation. Additionally, the new process gave the team a minimum standard that can be used for both new employee training and performance evaluation, according to Kaitlin Loos, RN, BSN, and Molly Siebert, RHIA, CCDS, in the new ACDIS white paper “CDI documentation standards: A health system story.”
As the process progressed at LHS, ACDIS published the white paper “How to conduct a medical record review,” which validates and supports the need for a CDI review process and thorough documentation and enhanced the efforts that were underway at the system. Loos and Siebert’s new paper provides a practical look at how an organization could develop their own process that works for their individual organizational and programmatic needs.