CLINICAL DOCUMENTATION IMPROVEMENT WORKFLOW

Created by ChecklistGuro (https://checklistguro.com)

[ ] Retrieve Patient Encounter Record: Fetch the clinical encounter data and patient demographics from the Patient Encounter data model.
[ ] Fetch Physician Documentation: Retrieve the recent clinical notes and discharge summaries written by the attending physician.
[ ] Calculate DRG Complexity Score: Execute a formula based on diagnosis severity and procedure intensity to determine the complexity level.
[ ] Identify Missing Clinical Indicators: Scan the retrieved documentation for missing required clinical elements (e.g., acuity, comorbidities).
[ ] Flag Documentation for Review: Update the status of the clinical record to 'Pending CDI Review' in the Encounter data model.
[ ] Assign CDI Specialist Review: Create a task for the assigned Clinical Documentation Improvement specialist to audit the chart.
[ ] Retrieve CDI Audit Checklist: Fetch the standard audit checklist template for the specific specialty being reviewed.
[ ] Create Query Record: Create a new entry in the 'Physician Queries' data model to track requests for clarification.
[ ] Update Query Status: Update the query record status to 'Open' once the specialist has identified a discrepancy.
[ ] Notify Physician of Query: Send an email to the attending physician containing the specific query details and a link to respond.
[ ] Retrieve Physician Response: Fetch the physician's clarification or amended note from the clinical documentation model.
[ ] Update Encounter with Clarified Data: Update the original Encounter record with the newly clarified diagnoses or severity of illness.
[ ] Calculate Monthly Query Response Rate: Aggregate all query entries for the current month to calculate the percentage of queries answered within 24 hours.
[ ] Final Coding Validation Task: Create a task for the Medical Coding team to finalize the codes based on the improved documentation.
[ ] Generate CDI Productivity Report: Create a report summarizing the number of charts reviewed, queries sent, and revenue impact identified.

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