Facilities or departments may determine critical areas of interest for focused CDI reviews based on quality indicators, length
of stay, mortality, readmissions, or other benchmarked data.
For example, CDI could conduct a targeted study to determine
how patient length of stay affects the occurrence of pressure ulcers, ultimately improving the standard of care for this population. Identifying links between activity levels, nutritional status, and the presence of comorbid conditions helps carve new
procedures, enhance documentation practices, and improve
nurse/provider communication while identifying the need for
improvement or confirming best professional practice. In this
way, patient safety outcomes are reflected by the efforts of the
CDI specialist working with physicians and coders to ensure appropriate capture of primary and secondary diagnoses for every
patient at every encounter. CDI specialists work to sort through
the complex medical record with concurrent or retrospective
reviews to determine the most appropriate code selection. 5
The CDI team may include previous direct care providers,
experienced coders, or a combination of both. This team approach yields quality documentation that will positively reflect
on patient safety scores. Record reviews and physician queries
resolve questions of causal relationships. For example, did a
medication cause an adverse effect in a patient because of dosing, underlying medical conditions, drug interactions, or intolerance to the substance? When examining why patients fall in
the hospital, this in-depth study could prevent future falls.
The goal of concurrent or retrospective documentation reviews by the CDI specialist enhances patient safety by ensuring
the first line of defense with consistency and accuracy within
the patient record. 6 Data analysts can then create descriptive
databases and produce statistical information with correct information, thus enhancing patient safety outcomes.
Data Analytics Team Searches for Significance
Data analysts compile large volumes of information to determine significant outcomes of care that may influence future
treatment modalities or avoid potentially dangerous situations
by identifying patterns and trends. 7 Precise data entry by clinical
staff at the bedside leads to more specified clarification of clinical documentation by CDI professionals, resulting in clean data
for statistical analysis. Decision-making processes begin with
benchmarking data to determine trends, correlations, or variances within a specific population.
Coded data can be sorted and arranged with ease, allowing the
data analyst to apply calculations. Information can be evaluated
within an organization with a prescribed timeline or compared
with reported data from archived databases with selected significance. In this way, healthcare professionals may not only establish new plans of care but determine the effectiveness of change.
Benchmarking is the driving force to assess the effectiveness or
need for improvement of performance and quality standards. 8
Since the advent of the electronic health record (EHR) system, a
streamlined approach to data management has paved the way to
new opportunities to improve patient outcomes. Accurate data
entry provides the groundwork for reporting and analyzing vast
quantities of information using a systematic approach.
Consolidated data entry provides an efficient manner in which
chart reviews are conducted for coding or auditing, and data is extracted for analysis or reporting. Identifying and monitoring patterns within the healthcare delivery system provide guidance for
system development, business management, and medical decision-making. Operational system alerts and enhanced order entry procedures can be established as a result of proper reporting
of concise data. The Office of the National Coordinator for Health
IT (ONC) was created in 2004 to “spur the widespread adoption of
the interoperable EHR within 10 years.” 9 Advanced education can
be developed to facilitate a deeper understanding of the importance of accurately and precisely capturing appropriate diagnosis
and procedure codes from provider documentation.
Connecting for Improved Patient Safety
The future of healthcare quality and safety can best be determined by the complete and accurate interpretation of the quality information in the patient record to include treatment modalities, patient safety indicators, and response to care including
outpatient follow-ups and quality measures.
Patient safety and quality care is the responsibility of all
healthcare professionals. The patient record remains the most
prominent method of communication between healthcare providers to include direct patient-specific care as well as understanding quality measures and performance outcomes to improve the management of population health initiatives. 10 From
facility and provider communication for each patient encounter
to the analysis of coded data, clinical documentation specialists
provide another link to quality and safety. ¢
1. Johns, Merida L. Enterprise Health Information Management
and Data Governance. Chicago, IL: AHIMA Press, 2015.
2. Abdelhak, Mervat H. et al. Health Information Management of a Strategic Resource, 5th Edition. St. Louis, MO:
3. Fahrenholz, Cheryl G. et al. Documentation for Health Records. Chicago, IL: AHIMA Press, 2013.
4. Abdelhak, Mervat H. et al. Health Information Management of a Strategic Resource, 5th Edition.
6. Johns, Merida L. Enterprise Health Information Management and Data Governance.
7. White, Susan. A Practical Approach to Analyzing Healthcare Data. Chicago, IL: AHIMA Press, 2016.
9. Johns, Merida L. Enterprise Health Information Management and Data Governance.
Teresa Evers ( Teresa.Ann.Evers@Outlook.com) has 30 years of clinical
nursing experience and five years of CDI experience.