T-System's team of expert analysts travel across the country to review, code and Q/A thousands of emergency medicine charts. We've analyzed this information for trends related to clinical documentation improvement (CDI), and found five common documentation deficiencies that have a negative impact on CDI.

1. Five Tips
for Optimizing
Clinical
Documentation
Improvement
in Emergency Medicine
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2. 2
#1 Documentation Deficiency
Failure to document medical necessity
for procedures.

3. 3
#1 CDI Optimization Tip
Make sure documentation of
an encounter tells a story.
• Why did the patient present for care?
• What did the provider do for the patient?
• Why did the provider do what he/she did?
Example:
When a NS bolus is ordered and administered, or CT of the head is ordered but any
symptoms or complaints that would support the need for this study must be documented.

4. 4
#2 Documentation Deficiency
Failure to document procedures
or its key components.

5. 5
#2 CDI Optimization Tip
Make sure that procedure information and the
key components are accurately documented.
Un- or under-documented procedures result in:
• Lost revenue
• Inability to charge for I&D
• Physicians losing costly procedures to the facility

6. 6
#3 Documentation Deficiency
Failure to document co-morbidities
influencing patient care.

7. 7
#3 CDI Optimization Tip
Make sure that physicians
explicitly state the patient’s
condition(s).

8. 8
#4 Documentation Deficiency
Failure to properly document details
on diagnosis.

9. 9
#4 CDI Optimization Tip
Ensure that documentation includes
these four key elements:
Acuity
Ex: acuity regarding
bronchitis
Location
Ex: location regarding
sinusitis
Cause
Sometimes this is not
known in emergency
medicine.
Manifestation
Ex: regarding diabetes
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10. 10
#5 Documentation Deficiency
Failure to support a diagnosis
with documentation in the exam.

11. 11
#5 CDI Optimization Tip
Document all pertinent findings in the
multi-system exam.
Consider this:
When the physician observes everything is normal in the exam, yet the clinical
impression states otherwise, there is a major issue.