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Encounter and Record Identification

Encounter type and setting are clearly identified critical (required)

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 critical (required)

Assess whether the chief complaint, admission diagnosis, or reason for visit is consistent across the record.

Yes No N/A

Relevant dates, author, and source documents are present

Confirm the record includes dated entries, author attribution, and supporting source documents needed for review.

Yes No N/A

Diagnostic Specificity and Clinical Support

Primary diagnosis is stated with sufficient specificity critical (required)

Check for organism, site, acuity, laterality, episode of care, and other required specificity when applicable.

Yes No N/A

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.

Yes No N/A

CC/MCC candidates are supported by clinical evidence critical (required)

Assess whether conditions that may qualify as CC/MCC are supported by exam findings, labs, imaging, treatment, or consults.

Yes No N/A

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.

Yes No N/A

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.

Yes No N/A

Documentation Consistency and Provider Query Readiness

Documentation is internally consistent across notes and disciplines critical (required)

Review for conflicting diagnoses, inconsistent problem lists, or mismatched assessment and plan statements.

Yes No N/A

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.

Yes No N/A

Potential query opportunities are identified

Determine whether missing specificity, conflicting documentation, or unsupported diagnoses should be sent for CDI clarification.

Yes No N/A

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.

Yes No N/A

Risk Adjustment and HCC Capture

Chronic conditions are addressed during the encounter critical (required)

Confirm active chronic conditions are assessed, monitored, treated, or discussed when relevant to the visit.

Yes No N/A

HCC-eligible conditions are supported by current documentation critical (required)

Verify the note supports risk-adjusting diagnoses with current assessment, treatment, or monitoring, not just historical mention.

Yes No N/A

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.

Yes No N/A

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.

Yes No N/A

Assessment, Plan, and Supporting Evidence

Assessment is supported by objective findings critical (required)

Check whether labs, imaging, vitals, exam findings, or other objective data support the documented assessment.

Yes No N/A

Treatment plan aligns with documented diagnoses

Verify medications, procedures, consults, monitoring, and discharge plans are consistent with the stated diagnoses.

Yes No N/A

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.

Yes No N/A

Findings, Deficiencies, and Follow-Up

Deficiencies are documented with specific examples critical (required)

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.

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Run: Clinical Documentation Integrity Review

Encounter and Record Identification

Diagnostic Specificity and Clinical Support

Documentation Consistency and Provider Query Readiness

Risk Adjustment and HCC Capture

Assessment, Plan, and Supporting Evidence

Findings, Deficiencies, and Follow-Up

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