fessionals should be trained on appropriate ways to review a
health record to identify documentation deficiencies, when a
physician query may be needed, and the parameters for constructing a compliant query. According to Hess, “The record review process should include addressing all components of the
patient record as possible sources for query opportunities.” 8
In general, physician queries should be constructed to clarify
conflicting, ambiguous, or incomplete information, obtain clinically relevant information not previously addressed within the
current documentation, and clarify present-on-admission indicator assignments. 9
For more information on constructing a compliant query,
reference AHIMA’s 2019 Practice Brief titled “Guidelines for
Achieving a Compliant Query Practice” and the AHIMA Inpatient Query Toolkit. Both are available online in AHIMA’s HIM
Body of Knowledge.
Training On Data Collection and Analysis
CDI professionals should be trained on how to collect data, how
to analyze the data collected, how to enter information into the
program database, and how to formulate and organize the data
for a physician query.
The collection of program data should include the identification of: 10
All cases reviewed
The number of cases with queries
The nature of the query
The physician’s response to the query
After initial training of CDI staff, a post-training evaluation
should be conducted to ensure the appropriate transfer of
knowledge has occurred and the CDI professional has a strong
grasp on key concepts. Post-training evaluation can also include
a “shadowing” program in which more experienced CDI professionals within the organization shadow newer staff in order to
ensure an effective training process.
Ongoing Education for CDI staff
Ongoing education for CDI staff is crucial to the ultimate success of the CDI program. Ongoing education can include additional coursework to obtain credentials such as the Certified
Documentation Improvement Practitioner (CDIP). Ongoing
training can also include choosing specific cases for review
within the CDI group as a learning opportunity to help all staff
continue to develop skills.
For more on current and future trends in CDI, please see the
extended online-only version of this Practice Brief, available in
AHIMA’s HIM Body of Knowledge. ¢
1. Seppälä, Emma and Kim Cameron. “Proof That Positive
Work Cultures Are More Productive.” Harvard Business Review. December 1, 2015. https://hbr.org/2015/12/proof-
3. Adler, Howard and Richard Ghiselli. “The Importance of
Compensation and Benefits on University Students’ Perception of Organization As Potential Employers.” Journal of
Management and Strategy 6 ( 1): 2015. http://www.sciedu.
5. AHIMA. Clinical Documentation Improvement Toolkit.
Chicago, IL: AHIMA Press, 2016. http://bok.ahima.org/
6. Hess, Pamela Carroll. Clinical Documentation Improvement: Principles and Practices. Chicago, IL: AHIMA Press,
2015. p. 157.
8. Ibid, p. 162.
9. AHIMA. “Guidelines for Achieving a Compliant Query
Practice (2019 Update).” Journal of AHIMA 90, no. 4 (April
2019): 36-41.http:// bok.ahima.org/doc?oid=302674.
10. Hess, Pamela Carroll. Clinical Documentation Improvement: Principles and Practices.
Tammy Combs, RN, MSN, CDIP, CCS, CCDS
Jennifer Daly, RN, MSN, CDIP, CCDS
Okemena Ewoterai, CDIP, CCS, CCDS
Chinedum Mogbo, MBBS, MsHIM, RHIA, CCDS, CDIP, CCS
Daphne I. Willis, MSA, RHIA, CPHQ, CDIP
Prepared By (2013)
Gloryanne Bryant, RHIA, CCS, CDIP, CCDS
Sheila Burgess, RHIA, CDIP, RN, HIT PRO-CP
Martin Conroy, RHIA
Nancy Lero, RN, BSN, CCDS, CDIP, CBCS
Ranae Race, RHIT
Carla Serrano, RHIT, CDIP, CCS, CCDS, CPC
Sheryl Theno, RHI T, CDIP
Lou Ann Wiedemann, MS, RHIA, CDIP, CPEHR, FAHIMA
Katherine Kozlowski, RHIA, CCS, CDIP, RMCC
Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS,
Donna Rugg, RHIT, CDIP, CCS-P, CICA, CCS
Robyn Stambaugh, MS, RHIA
Sandy Bundenthal, RHIA, CCS
Appendices Available Online
There are four appendices available in the online version of
this Practice Brief, available in AHIMA’s HIM Body of Knowledge:
• Appendix A: Key Points in Developing a CDI Program
• Appendix B: Orientation for New CDI Professionals
• Appendix C: Ongoing Education Plan
• Appendix D: Qualitative Productivity Tool Example