Five Tips for Optimizing

Clinical

Documentation

Improvement

in Emergency Medicine

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#1 Documentation Deficiency Failure to document medical necessity

for procedures.

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#1 CDI Optimization Tip

• 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.

Make sure documentation of

an encounter tells a story.

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#2 Documentation Deficiency Failure to document procedures

or its key components.

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Un- or under-documented procedures result in:

• Lost revenue

• Inability to charge for I&D

• Physicians losing costly procedures to the facility

#2 CDI Optimization TipMake sure that procedure information and the

key components are accurately documented.

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#3 Documentation Deficiency Failure to document co-morbidities

influencing patient care.

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#3 CDI Optimization TipMake sure that physicians

explicitly state the patient’s

condition(s).

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#4 Documentation Deficiency Failure to properly document details

on diagnosis.

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Acuity Ex: acuity regarding

bronchitis

LocationEx: location regarding

sinusitis

#4 CDI Optimization TipEnsure that documentation includes

these four key elements:

CauseSometimes this is not

known in emergency

medicine.

ManifestationEx: regarding diabetes

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#5 Documentation Deficiency Failure to support a diagnosis

with documentation in the exam.

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#5 CDI Optimization Tip

Consider this:When the physician observes everything is normal in the exam, yet the clinical

impression states otherwise, there is a major issue.

Document all pertinent findings in the

multi-system exam.