Clinical Documentation Specialists (CDS) perform concurrent reviews of inpatient medical records and query providers for:
The condition established after study to be chiefly responsible for occasioning the admission.
Secondary Diagnosis / Comorbid Conditions
Additional conditions present at the time of admission or developed while in the hospital that affects the care path for the patient or current hospital episode.
Documentation of secondary conditions affects the patient severity of illness profile.
Problem lists should be updated with each inpatient hospitalization.
All medications and treatments should have a corresponding diagnosis.
All diagnoses should be documented consistently in the progress notes with a clear treatment plan.
Signs and symptoms should be defined by underlying diagnoses if known.
Coding Guidelines State
Establish and/or validate diagnoses:
Present on Admission (POA)
It is important to clearly document if a condition was POA; if unable to determine if a condition was POA, document as such.
Certain conditions if not POA are perceived as an indicator of poor care. Make documentation clear and ensure true depiction of care is reflected in coding.
Hospital Acquired Conditions (HACs)
Considered to be "preventable."
If the condition was NOT present on admission it is categorized as "provider-preventable."
HACs as of 2015:
General Documentation Tips
If you receive a query and there is no definitive diagnosis or clinical significance, respond and let the Clinical Documentation Improvement (CDI) team know.