Clinical Documentation Improvement Checklist
Comprehensive clinical documentation improvement review ensuring accurate capture of patient acuity and appropriate coding.
- Industry: Healthcare
- Frequency: Per admission/Concurrent
- Estimated Time: 15-20 minutes
- Role: CDI Specialist
- Total Items: 29
- Compliance: ACDIS Guidelines, CMS Documentation, ICD-10 Coding Guidelines
Principal Diagnosis
Primary diagnosis specificity
- Principal diagnosis clearly documented?
- Diagnosis specificity adequate?
- Clinical indicators support diagnosis?
Secondary Diagnoses
Comorbidities and complications
- All comorbidities captured?
- Complications documented?
- CC/MCC potential identified?
Procedures
Procedure documentation
- All procedures documented?
- Surgical approach documented?
Physician Queries
Query process
- Clarification query needed?
- Query sent to physician?
- Query response received?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Medication Safety & Management
Verify medication handling and administration practices
- Medications stored securely and at proper temperature?
- Controlled substances properly secured and counted?
- No expired medications in stock?
- High-alert medications properly labeled?
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Why Use This Clinical Documentation Improvement Checklist?
This clinical documentation improvement checklist helps healthcare teams maintain compliance and operational excellence. Designed for cdi specialist professionals, this checklist covers 29 critical inspection points across 8 sections. Recommended frequency: per admission/concurrent.
Ensures compliance with ACDIS Guidelines, CMS Documentation, ICD-10 Coding Guidelines. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Clinical Documentation Improvement Checklist cover?
This checklist covers 29 inspection items across 8 sections: Principal Diagnosis, Secondary Diagnoses, Procedures, Physician Queries, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed per admission/concurrent. Each completion takes approximately 15-20 minutes.
Who should use this Clinical Documentation Improvement Checklist?
This checklist is designed for CDI Specialist professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.