Queryless CDI?: A Smarter Way to Elevate Clinical Documentation

HITEKS Solutions Inc.

Clinical Documentation Integrity (CDI) programs traditionally rely on query systems to close documentation gaps between clinical observations and the coding required for billing and quality reporting.?

Physicians document patient care in clinical language, but coders need structured data to assign codes that reflect diagnoses and procedures. Queries help clarify ambiguous, missing, or inconsistent information to ensure the coded data aligns with the clinical intent.?

However, these queries often occur retrospectively, creating workflow disruptions, delays, and administrative burdens—leading to inefficiencies that Queryless CDI? seeks to eliminate through proactive, real-time documentation support.

Powered by HITEKS within Epic’s environment, Queryless CDI? helps physicians get documentation right the first time—seamlessly, in real-time, without the traditional back-and-forth.

Bridging the Gap Between Clinical and Coded Notes

Instead of relying on retrospective queries that disrupt workflows, Queryless CDI? offers proactive point-of-care documentation. Physicians receive real-time prompts within Epic’s NoteReader CDI and Diagnosis Aware Notes (DAN), helping them capture accurate details as they write—before signing the note or discharging the patient.

Why Queryless CDI? Matters

1. Accuracy from the Start Get your coding right the first time. With CAPD suggestions embedded directly in the physician’s workflow, documentation errors and missed diagnoses are minimized.
2. Seamless Workflow for Providers No more interruptive post-discharge queries. Physicians work uninterrupted within Epic, with prompts aligned to their clinical logic. This real-time guidance reduces the need for addendums and streamlines CDI processes.
3. CDI Benefits Across the Care Spectrum Queryless CDI? isn’t just for inpatient care. It powers tailored workflows for CDI specialists (CA-CDR) and ambulatory care teams, ensuring documentation integrity across all settings.

Efficiency Meets Compliance

DAN’s semi-automation syncs the problem list with the note, eliminating redundancy and improving documentation consistency. Physicians benefit from:

• Reduced administrative burden
• Decreased retrospective queries
• Better alignment with payer compliance requirements

The Next Generation of CDI Innovation?

With Queryless CDI?, hospitals no longer need to struggle with outdated query systems. Proactive documentation and in-note prompts mean less friction, more efficiency, and higher coding accuracy.

Get in touch with our team to learn ways to reduce the noise and elevate your CDI strategy.

Explore the future of seamless, compliant documentation with Queryless CDI?—integrated deeply within Epic for better outcomes today.