Clinical Documentation Integrity Review

Inspection template for reviewing clinical documentation specificity and completeness to support accurate CDI, coding, CC/MCC, SOI/ROM, and HCC capture.

Encounter and Record Identification

• Encounter type and setting are clearly identified
  Verify the record identifies the correct encounter type, such as inpatient, observation, emergency department, outpatient, or professional service.
• Principal reason for encounter is documented consistently across notes
  Assess whether the chief complaint, admission diagnosis, or reason for visit is consistent across the record.
• Relevant dates, author, and source documents are present
  Confirm the record includes dated entries, author attribution, and supporting source documents needed for review.

Diagnostic Specificity and Clinical Support

• Primary diagnosis is stated with sufficient specificity
  Check for organism, site, acuity, laterality, episode of care, and other required specificity when applicable.
• Secondary diagnoses are documented with clinical significance
  Verify comorbidities and active conditions are documented as affecting care, treatment, monitoring, or length of stay when applicable.
• CC/MCC candidates are supported by clinical evidence
  Assess whether conditions that may qualify as CC/MCC are supported by exam findings, labs, imaging, treatment, or consults.
• Acuity, severity, and status terms are clearly documented
  Check for documentation of acute, chronic, exacerbation, resolved, ruled out, suspected, or history-of status where clinically appropriate.
• Laterality, anatomic site, and episode details are captured when relevant
  Confirm laterality, body site, trimester, encounter type, or other code-specific details are included when applicable.

Documentation Consistency and Provider Query Readiness

• Documentation is internally consistent across notes and disciplines
  Review for conflicting diagnoses, inconsistent problem lists, or mismatched assessment and plan statements.
• Unclear, vague, or non-specific terminology is minimized
  Check for terms such as 'rule out,' 'possible,' 'likely,' 'history of,' or 'questionable' without follow-up clarification when needed for coding.
• Potential query opportunities are identified
  Determine whether missing specificity, conflicting documentation, or unsupported diagnoses should be sent for CDI clarification.
• Documentation supports medical necessity and level of service
  Verify the record supports the intensity of service, decision-making, and resource use documented in the encounter.

Risk Adjustment and HCC Capture

• Chronic conditions are addressed during the encounter
  Confirm active chronic conditions are assessed, monitored, treated, or discussed when relevant to the visit.
• HCC-eligible conditions are supported by current documentation
  Verify the note supports risk-adjusting diagnoses with current assessment, treatment, or monitoring, not just historical mention.
• Status and history conditions are documented appropriately
  Check that history of cancer, amputations, organ transplant, or other status conditions are documented accurately and distinctly from active disease.
• Risk-adjusting conditions are linked to care plan or follow-up
  Confirm the note includes management, monitoring, medication changes, referrals, or follow-up related to the condition.

Assessment, Plan, and Supporting Evidence

• Assessment is supported by objective findings
  Check whether labs, imaging, vitals, exam findings, or other objective data support the documented assessment.
• Treatment plan aligns with documented diagnoses
  Verify medications, procedures, consults, monitoring, and discharge plans are consistent with the stated diagnoses.
• Discharge or follow-up instructions address active conditions
  Confirm the discharge summary or follow-up plan includes unresolved conditions, pending results, and next steps when applicable.

Findings, Deficiencies, and Follow-Up

• Deficiencies are documented with specific examples
  Record the exact documentation gaps, contradictions, or missing specificity identified during the review.
• Recommended CDI or coding follow-up is identified
  Select the follow-up actions needed based on the review findings.
• Reviewer summary and disposition
  Summarize whether the record passed, passed with deficiencies, or requires follow-up action.