HEALTHCARE CLINICAL DOCUMENTATION IMPROVEMENT (CDI) CHECKLIST 2026 Created by ChecklistGuro (https://checklistguro.com) --- PRE-REVIEW & PATIENT RECORD INTEGRITY --- [ ] Record Review Date [ ] Patient Medical Record Number (MRN) [ ] Reviewer Identity (CDI Specialist, Clinical Auditor, Physician Lead) [ ] Initial Documentation Components Present (Admission Note, Progress Notes, Discharge Summary, Consultation Reports) [ ] Discrepancies Found in Patient Identity or Record Setup [ ] Auditor Verification Signature --- CLINICAL SPECIFICITY & GRANULARITY --- [ ] Diagnosis Specificity Level (Fully Specified (Meets ICD-10 Criteria), Vague/Unspecified (Requires Query), Incomplete/Missing Laterality) [ ] Missing Granularity Elements (Laterality (Left/Right/Bilateral), Acuity/Severity (Acute/Chronic), Anatomical Site/Location, Etiology/Cause, Stage/Severity Grade) [ ] Identified Ambiguous Terms [ ] Clinical Documentation Improvement Notes [ ] Number of Queries Initiated --- PHYSICIAN QUERY PROCESS & DOCUMENTATION ACCURACY --- [ ] Query Date [ ] Query Type (Clarification, Addition, Conflict Resolution, Specificity Improvement) [ ] Documentation Discrepancies Identified (Missing Clinical Indicators, Conflicting Physician Notes, Incomplete Diagnosis, Inconsistent Lab/Imaging Correlation) [ ] Description of Clinical Query Detail [ ] Reviewer/Physician Acknowledgement [ ] Supporting Clinical Evidence (Labs/Imaging) --- COMORBIDITY & COMPLICATION (CC/MCC) CAPTURE --- [ ] Identified CC/MCC Indicators (Sepsis (Sepsis-3 criteria met), Acute Respiratory Failure, Acute Kidney Injury (AKI), Encephalopathy, Malnutrition, Other CC/MCC identified) [ ] Clinical Evidence for CC/MCC [ ] Discrepancy Details & Query Summary [ ] Impact on DRG Assignment (Increased Weight (Shift to higher DRG), No Change to DRG, Potential Under-coding Detected) [ ] Date of Documentation Review [ ] CDI Specialist Verification --- CLINICAL INDICATORS & EVIDENCE ALIGNMENT --- [ ] Clinical Indicator Present (Yes, No, Inconclusive/Requires Query) [ ] Supporting Evidence Sources (Laboratory Results, Radiology/Imaging Reports, Nursing Progress Notes, Vital Signs Trends, Pathology Reports, Physician Consult Notes) [ ] Discrepancy Identified [ ] Analysis of Clinical Evidence Alignment [ ] Supporting Lab/Imaging Documentation [ ] Date of Clinical Evidence Review --- CODING & REIMBURSEMENT ALIGNMENT --- [ ] Assigned DRG (Diagnosis Related Group) (DRG Verified, Discrepancy Found, Pending Query) [ ] Discrepancy Types Identified (Under-coding of CC/MCC, Inaccurate Procedure Code, Mismatched Clinical Indicators, Unsupported Diagnosis) [ ] Coding Discrepancy Notes [ ] Estimated Reimbursement Impact ($) [ ] Audit Completion Date [ ] Compliance Officer Authorization --- COMPLIANCE & REGULATORY STANDARDS --- [ ] Regulatory Frameworks Applied (CMS Guidelines, HIPAA Privacy/Security, The Joint Commission (TJC) Standards, State Department of Health Requirements) [ ] Compliance Audit Status (Fully Compliant, Minor Deficiencies Found, Major Non-Compliance Identified) [ ] Date of Compliance Review [ ] Regulatory Gap Analysis & Findings [ ] Compliance Officer Verification [ ] Supporting Evidence & Audit Documentation --- POST-REVIEW FEEDBACK & PHYSICIAN EDUCATION --- [ ] Review Completion Date [ ] Physician Feedback Category (Educational Opportunity Identified, Documentation Error Corrected, No Intervention Required, Query-Driven Clarification) [ ] Summary of Clinical Feedback Provided [ ] Targeted Improvement Areas (Specificity of Diagnosis, Linkage of Clinical Indicators, Acuity/Severity Documentation, Timeliness of Documentation) [ ] CDI Specialist Verification --- END OF TEMPLATE --- Transform this text into a digital, automated, and trackable mobile app! Visit: https://checklistguro.com/templates/healthcare/healthcare-clinical-documentation-improvement-cdi-checklist-2026 (Click "Install Template" to launch your digital inspection tool immediately)