Clinical Documentation Improvement (CDI) programs can come in many forms. However, there is increasing evidence that programs focusing on concurrent reviews of inpatient episodes set themselves up for the best chance at sustainable success. By addressing documentation issues while the patient is still in a bed, concurrent Clinical Documentation Specialist (CDS) reviews promote real-time improvements in clinical documentation accuracy leading to better communication and improving hospital operations and patient safety.
Concurrent CDS reviews involve real-time assessment of clinical documentation by CDI professionals while the patient is still receiving care. This proactive approach ensures that documentation gaps or inaccuracies are identified and corrected before the patient is discharged. Unlike retrospective models, concurrent reviews allow for immediate engagement with clinical staff, providing timely education and feedback that ensures the medical record accurately reflects the patient's condition and the care provided at the time of care.
The importance of accurate documentation cannot be overstated. Poor documentation can lead to adverse events, errors, misdiagnosis, inappropriate treatment, or poor care outcomes. Concurrent CDS reviews help mitigate these risks by ensuring that clinical documentation is both timely and accurate, with an emphasis on improving patient safety and care quality.
During a concurrent review, a CDS evaluates the medical record like a detective, scrutinising the quality and specificity of diagnoses, comorbidities, complications, treatment changes, and care plans. They assess the documentation of underlying conditions, discharge summaries, and the links between care plans and diagnoses. The primary objective is to enhance the communication within the record which in turn improves data integrity through accurate clinical coding.
Moreover, this real-time process fosters collaboration among the care team - clinicians, nurses, allied health professionals, and CDS professionals - ensuring accurate and complete documentation at the time of care, which improves coordination and communication across the team.
Concurrent CDS reviews not only improve documentation quality but also enhance workflow efficiency and reduce administrative burdens for hospitals. By identifying and rectifying documentation gaps in real time, CDS professionals help prevent downstream delays in coding, and for private facilities, delays in billing.
This approach alleviates the reliance on the often cumbersome and time-consuming documentation query process used in retrospective reviews. Instead of generating and chasing after documentation queries long after the patient has left, concurrent reviews allow hospitals to address issues while the patient is still in care. This eliminates the need for extensive post-discharge documentation corrections, making the process far more operationally efficient and reducing the burden on coding and health information teams.
Embracing innovative and advanced technologies is increasingly essential for the successful implementation of concurrent CDS reviews. Many healthcare organisations in Australia are transitioning to electronic health records (EHRs), with some already adopting computer-assisted coding software and CDI tools that can support concurrent reviews.
These technological solutions provide real-time access to patient data, allowing CDS professionals to promptly identify and address incomplete or inaccurate documentation. Tools powered by natural language processing (NLP) and artificial intelligence (AI) can analyse the medical record and alert CDSs to documentation gaps. While useful in retrospective reviews, such technology shines in concurrent reviews, enabling CDS professionals to review and address documentation issues before coding occurs.
Moreover, technology facilitates data analysis and reporting, helping hospitals track key performance indicators (KPIs) and monitor the success of their concurrent CDS reviews. This data can be used to continuously improve CDI programs, making them more effective and efficient over time.
Not implementing concurrent CDS reviews can pose significant risks to your CDI program. Without real-time reviews, hospitals must rely on retrospective documentation queries to correct documentation errors. This approach is limiting for several reasons.
First, it leads to delays in coding and billing, which can negatively impact reimbursement and revenue cycle management. Second, it places an additional burden on coding and health information teams, who must spend hours generating and following up on queries that could have been resolved during the patient's stay. This inefficient process not only wastes time but also prevents the CDI program from addressing one of its main objectives: fostering a culture of documentation excellence among clinicians.
Without concurrent reviews, hospitals miss the opportunity to provide real-time feedback and education to clinicians, leaving documentation issues unresolved until after the fact. This makes it much harder to achieve long-term improvements in documentation quality and to change entrenched behaviours among clinical staff.
Many healthcare organisations have successfully integrated concurrent CDS reviews into their CDI programs, seeing measurable improvements in documentation accuracy, operational efficiency, and patient safety. Hospitals that have adopted concurrent reviews report fewer documentation queries, faster coding processes, and a more engaged clinical workforce. These organisations also tend to experience improved reimbursement or funding rates and stronger data integrity, demonstrating the value of real-time documentation assessments.
Concurrent CDS reviews are essential for achieving sustainable improvements in clinical documentation integrity. Without this real-time approach, healthcare organisations may struggle to address documentation gaps or inaccuracies in a timely manner, compromising both operational efficiency and patient safety.
The collaboration enabled by concurrent reviews ensures that documentation is accurate and complete at the time of care, leading to better communication among the care team and more streamlined workflows. By leveraging technology and fostering a strong relationship between CDI professionals and coders, hospitals can optimise the impact of their concurrent reviews, achieving both short-term and long-term success.
In conclusion, implementing concurrent CDS reviews is not just a strategic advantage - it is crucial for improving documentation integrity, enhancing operational efficiency, and promoting better patient care outcomes. By addressing documentation behaviours in real time, hospitals can create a culture of accuracy and excellence, setting themselves up for sustained success in CDI.