Documentation Detective: Seven Steps to CDI Foundational Success

By Tammy Combs, RN, MSN, CDIP, CCS, CCDS

When an architect draws up plans for a building, they pay close attention to the details of the foundation. This provides the support to the building and prevents it from crashing down at any moment. If the building later has structural damage it is easy to fix when the foundation is not impacted. If they have to repair the foundation then they may be required to pick apart the entire structure to get to the problem area.

The structure of a CDI program is much like that of a building; it also needs a solid foundation to support its structure. A solid foundation will lead to the future success of the program. Figuring out the foundation can be a challenging task. It is not only challenging at the beginning but also throughout the management of the program. If you build a strong foundation then opportunity for growth becomes easier because the necessary operational pieces are already in place.

Below are seven steps to help guide you through the process of building a strong foundation. They can be used for a new program or a program that is looking to grow. Each organization will be different in their foundational needs. Flexibility is a key component to ensuring the program supports each unique need of your organization.

Step to Success

Step 1: Gap Analysis

  • Identify your patient population by gathering data for a gap analysis. You may need to reach out to several different departments to get the information you need. The areas where a gap is identified are the ones you may want to consider including into your reviews. If you have several gaps, you may want to start with the largest area and then build your program from there. Some suggested data to analyze includes: Case Mix Index (CMI)
  • Severity of Illness (SOI) and/or Risk of Mortality (ROM)
  • Patient Safety Indicators (PSI)
  • Hospital-Acquired Conditions (HAC)
  • Core Measures
  • Denial Rates
  • Hierarchical Condition Categories (HCC)

Step 2: Budget Your Staffing Needs

You may need to start small and work your way up. Remember it is easier to expand than to downsize a program. Be realistic—how many records will need to be reviewed per day? It may take a CDI specialist 20-30 minutes to complete a thorough review depending on the length of stay and acuity of the patient. Points to consider include:

  • Number of staff
  • Credentials required (i.e., RN, RHIA/RHIT, CCS, CDIP)
  • Equipment
  • Office space

Step 3: What Type of Review Will You Do?

The type of review you do will depend on the area you are reviewing and the specific patient population. The goal is to have the review done as close to the time of care being delivered as possible. The two types of reviews are listed below:

  • Concurrent (before discharge)
  • Retrospective (after discharge)

Step 4: Think About Review Process Logistics

Identify the location of the staff while performing reviews—it is important to think about the logistics of the review process. Now that many records are electronic, some programs are moving to more of a remote review process. Take into consideration the level of engagement you are receiving from physicians. If they are engaged and respond to queries in a timely manner, then a remote program may be a good choice. If the engagement level and response rate are low, however, they may need more face-to-face time before you want to go that route. Some area options are listed below:

  • Hospital unit
  • Hospital office
  • Home office

Step 5: Provide Clear Guidance to Your Team

Many facilities have a steering committee in place, with a senior leader to help guide the program. The leadership structure needs to have enough detail for the team to feel supported and know to whom they should direct questions. Recommended elements of this committee include:

  • Leadership structure
  • Clear policies and procedures
  • Process flow map
  • Escalation policy

Step 6: Measuring Success

Once the program has been implemented you will need to measure the success and report the metrics out to leadership and the team. This will guide you to the next steps by having an ongoing gap analysis in place.

  • CDI Metrics
    • CMI
    • Review rate
    • Query rate
    • Response rate
    • Response time
    • Quality/Revenue Impact
  • Reporting
    • Leadership
    • Team members


Documentation requirements are continually changing, ongoing education is a must for a team to stay on top of the latest information. Education opportunities include:

  • Webinars
  • Articles
  • Workshops
  • Team Collaboration

The CDI team can impact several other teams within an organization; it is good to have ongoing collaboration to create a comprehensive program.

Below are a couple of charts that identify some potential areas of opportunity your CDI program may want to explore. Always remember CDI is about capturing the true story of the patient that is supported by the clinical evidence and treatment. By unveiling the truth with high quality clinical documentation, success is already won.

Tammy Combs, RN, MSN, CDIP, CCS, CCDS, is director and lead nurse planner of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members, the media, and outside organizations on clinical documentation improvement (CDI) practice issues. Combs authors material and provides support for AHIMA’s online CDI education platforms. She also serves as faculty for the AHIMA CDI Academies and CDIP Exam Preps, and is a technical advisor for AHIMA on CDI publications.

Original source:
Combs, Tammy. "Documentation Detective: Seven Steps to CDI Foundational Success" (Journal of AHIMA website), January 27, 2016.