Documentation Check List

The CDI profession promotes itself as achieving Clinical Documentation Integrity through chart review and identifying opportunities for physician documentation improvement. I was recently asked to put together a list of common insufficiencies in physician documentation that can be addressed through CDI intervention. If the CDI specialists identify more than three of these insufficiencies in documentation, then the likelihood is high that the admission will be downgraded to Observation versus Inpatient Level of Care or denied based upon medical necessity which is costly to the facility and potentially to the patient. I would like to stress that these insufficiencies cannot be addressed through the query process. Use this check-off list as the starting point for physician documentation training. An excellent place to start documentation training is using cases downgraded to Observation in payer determinations and identifying any documentation insufficiencies or oversights as I like to refer to them, then meeting with the physician and pointing out areas of documentation to focus upon and strengthen moving forward. Frame the discussion around opportunities for Continuous Quality Improvement

• Absence of Chief Complaint or Chief Complaint as a Diagnosis
• History of Present Illness that does not adequately tell, describe, depict, and reflect the patient’s clinical story and severity of illness, documentation of at least four elements of HPI
• More focus upon past illness in the HPI versus the current illness.
• Lack of ED summary assessment within the HPI to best tell the patient story from time of presentation to the ED, pertinent management and treatment in the ED, and what where the clinical factors contributing to the medical decision to hospitalize the patient
• Documentation distinguishing what the patient was like when seen in the ED vs when the patient is being seen for the H&P, there may be vast differences between the two
• Physical Exam Constitutional that describes and represents a stable patient such as “Alert and Oriented X 3” in no current distress resting comfortably in bed
• Missing elements of Physical Exam relevant to patient’s clinical presentation
• Constitutional portion of the Physical Exam incongruent with the History of Present Illness- documentation does not correlate with patient illness and signs/symptoms in?HPI
• Vital signs not included in the Constitutional Physical Exam
• Normal results of clinically relevant parts of the Physical Exam pertinent to patient’s clinical presentation that are not explained/commented in the Assessment (Lungs CTA when pneumonia documented in Assessment)
• Differential diagnosis(es) not included in Assessment/Impression when clinically warranted- a list of possible clinical conditions that could be causing a person’s symptoms
• Lack of clinical support of Acute and/or Differential Diagnosis(es) found within the record
• ?Lack of clinical specificity in diagnosis(es) in Assessment
• Clinical rationale, clinical thought processes, and clinical criteria for acute definitive and/or provisional diagnosis(es) not documented in Assessment/Impression
• Clinical facts and clinical information that do not support an Acute and/or Differential Diagnosis(es) in the Assessment/Impression
• Acute and/or Differential Diagnosis(es) included in Assessment/Impression without being addressed in the History of Present Illness
• Plan of care orders do not match up one-to-one to diagnoses in Assessment/Impression
• Plan of care orders?suggest a Definitive and/or Differential Diagnosis(es) not included in the Assessment/Impression
• Lack of documentation of clinical significance of abnormal lab or radiology results or other results of workup
• Diagnoses directly related to the reason for hospitalization appearing in the Assessment that cannot be traced back to patient’s signs/symptoms, abnormal findings, abnormal workup results, management in Emergency Department with treatment. Diagnoses without clinical facts and clinical information set up the diagnosis for clinical validation denials
• Diagnoses representing a CC/MCC included in the Assessment without physician documentation of how the diagnoses impacts the clinical complexity of working up and managing the clinical conditions(es) occasioning the hospitalization
• Diagnosis(es) without corresponding documentation of plan of care. Plan of care should be traceable back to each diagnosis documented in the assessment. Plan of care should be reasonable, congruent with, and corelate with each diagnosis documented in the Assessment
• Lack of clinical specificity of diagnoses documented in the Assessment with cause-and-effect relationship, type, acuity, and clinical indicators
• Symptom (s) documented within Assessment without inclusion of potentially clinically relevant acute diagnoses physician is considering and working up that helps to explain the reason for ?hospitalization. These include but are not limited to “Can’t Miss Diagnoses.” These can be captured in the following format- Differential Diagnoses, Provisional Diagnoses, or Diagnostic Considerations
• Lack of documentation that captures the physician’s clinical judgement, medical decision making, thought processes, and clinical rationale associated with diagnoses that occasioned the hospitalization. “Naked Diagnoses” without the inclusion of this information aids and abets the payer in issuing clinical validation denials

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